This is to certify that the
thesis entitled

THE EFFECTIVENESS OF MUSIC THERAPY INVOLVING FAMILY
MEMBERS OF TERMINALLY ILL PATIENTS IN HOSPICE ON
QUALITY OF LIFE OF THE PATIENT AND STRESS LEVELS OF
FAMILY MEMBERS

presented by

Ayumu Kitawaki

has been accepted towards fulfillment
of the requirements for the

MM. degree in Music Therapy

 

 

Major Professor’s Signature

/; Z 43 Io?
I

Date

 

 

MSU is an affirmative-action, equal-opportunity employer

- -.—-I-I-I-u-v-l-0-I-U-O-O-I-I-I-l-l--I-I-I-I-I-I-U-O-l-O-O-I-O-I-O-O-O-I-l-I-I-

 

PLACE IN RETURN BOX to remove this checkout from your record.
To AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5/08 K lPrq/AchrelelRC/DateDue indd

THE EFFECTIVENESS OF MUSIC THERAPY INVOLVING FAMILY MEMBERS
OF TERMINALLY ILL PATIENTS IN HOSPICE ON QUALITY OF LIFE OF THE
PATIENT AND STRESS LEVELS OF FAMILY MEMBERS
By

Ayumu Kitawaki

A THESIS

Submitted to
Michigan State University _
in partial fulfillment of the requirements
for the degree of

MASTER OF MUSIC
Department of Music Therapy

2007

ABSTRACT
THE EFFECTIVENESS OF MUSIC THERAPY INVOLVING FAMILY MEMBERS
OF TERMINALLY ILL PATIENTS IN HOSPICE ON QUALITY OF LIFE OF THE
PATIENT AND STRESS LEVELS OF FAMILY MEMBERS
By
Ayumu Kitawaki

The purpose of the present study was to investigate the mutual effectiveness of music
therapy involving family members in improving quality of life (QOL) of terminally ill
patients and decreasing stress levels (STL) of their family members. A triangulation
design of mixed method was used, which used both quantitative data that was collected
with the Quality of Life Questionnaire for the patients and with SCARED for their family
members’ STL, and qualitative data. This research project included two cases (two
separate patient/significant loved one pairs). In Case One, no changes were found in QOL
and STL for the patient and loved one, respectively, in the quantitative analysis. In the
qualitative analysis, the patient’s spouse stated that a song written and mandala drawn by
the couple became meaningful to the patient’s wife and their friends to always remember
the patient. Significant improvement in QOL and STL in Case Two were found, and
qualitative data also support the mutual effectiveness of music therapy for this couple.
Improvisation strongly assisted both the patient and her husband to more deeply access
their feelings, open them up, and extemalize them. The patient expressed that a “happy

ending” was being surrounded by her family, going to heaven, meeting God, and having

no pain, while her spouse accepted the reality of loss, despite his earlier denial.

Copyright by
AYUMU KITAWAKI

2007

This thesis is dedicated to Yoshio Murata, my grand father
and

Akihisa Ishihara, my brother in law,

who gave me encouragement and passion about supporting terminally ill patients and

their families and enabling such a study to take place today.

iv

ACKNOWLEDGMENTS

First of all, my gratitude must go to my supervisor, Frederick Tims, Ph.D., MT-BC, who
gave me so much support through his understanding, patience, and encouragement.
Without his support, this research study would not have been completed. I am also
thankful for his insight with his wide knowledge cultivated by longtime experiences,
which enriched not only this study but also my career as a music therapist. I would like to
thank the other members of my committee, Dr. Karen Ogle, MD, and Roger Smeltekop,
MM, MT-BC, for their insights for this research study.

I also would like to thank my family for the support they provided me through my
entire life, particularly; I must thank my wife, Kayoko, and our son soon to be born, Haru.
I would not have been able to complete this whole process of the research study without

their encouragement.

TABLE OF CONTENTS

LIST OF TABLES ......................................................................................................... viii
LIST OF FIGURES .......................................................................................................... ix
CHAPTER ONE
Introduction ........................................................................................................................ 1
CHAPTER TWO
Literature Review .............................................................................................................. 3
Terminally ill patients .................................................................................................. 3
Family of a patient with terminal illness ..................................................................... 7
Music therapy involving family members ................................................................... 8
Mutual effectiveness of music therapy ...................................................................... 11
Expression, communication, reminiscence, life review, and validation .................... 18
Individualized music therapy plan ............................................................................. 20
Qualitative, case, and quantitative study ..................................................................... 21
Purpose and Problems ...................................................................................................... 22
CHAPTER THREE
Method ............................................................................................................................. 23
Research design ........................................................................................................ 23
Participants ............................................................................................................... 23
Procedures ................................................................................................................ 25
Testing materials ...................................................................................................... 25
Data gathering .......................................................................................................... 27
Musical instruments ................................................................................................. 27
Music therapy activities ........................................................................................... 28
CHAPTER FOUR
Data Analysis ................................................................................................................... 30
Quantitative data ....................................................................................................... 3O
Qualitative data ......................................................................................................... 30
CHAPTER FIVE
Case One: Tim and Mary ............................................................................................... 33
The clients ................................................................................................................. 33
Quantitative data ....................................................................................................... 35
Qualitative data ......................................................................................................... 4O
Singing-along, the way of reminiscence ........................................................... 4O
Improvisation and mandala ............................................................................... 42
Song writing, memories and distraction ........................................................... 46

vi

CHAPTER SIX

Case Two: Betty and James ............................................................................................. 49
The clients ................................................................................................................. 49
Quantitative data ....................................................................................................... 51
Qualitative data ......................................................................................................... 65

Dancing as remembering good old days ........................................................... 66
Outside music therapy interventions ................................................................. 66
Singing-along and fill-in-blank to express happiness ....................................... 67
Happy ending with family in improvised music and life .................................. 68
Scary, sad, and support by family ...................................................................... 71
Projecting life experience and emotion deep inside in music ........................... 71

CHAPTER SEVEN

Discussion and Conclusions ............................................................................................. 77
Case One ................................................................................................................... 77
Case Two .................................................................................................................. 79
Implications from two cases ..................................................................................... 81
Recommendations for future research ...................................................................... 83
Conclusion ................................................................................................................ 84

APPENDD( A ................................................................................................................... 86

APPENDIX B ................................................................................................................... 89

BIBLIOGRAPHY ........................................................................................................... 92

vii

LIST OF TABLES

Table 1. Means and Standard Deviation on Quality of Life Questionnaire .................... 37
Table 2. Repeated Measures ANOVA: Quality of Life Questionnaire ........................... 37
Table 3. Means and Standard Deviation on SCARED ................................................... 39
Table 4. Repeated Measures ANOVA: SCARED .......................................................... 39
Table 5. Summary of Improvisation in Session 1 ........................................................... 44
Table 6. Means and Standard Deviation on Quality of Life Questionnaire ..................... 53
Table 7. Repeated Measures ANOVA: Quality of Life Questionnaire ........................... 53
Table 8. Quality of Life Comparisons .............................................................................. 54
Table 9. Means and Standard Deviation on SCARED .................................................... 60
Table 10. Repeated Measures ANOVA: SCARED ......................................................... 60
Table 11. SCARED Comparisons .................................................................................... 61
Table 12. Summary of the First Improvisation in Session 2 ........................................... 69
Table 13. Summary of the Second Improvisation in Session 3 ..................................... 70
Table 14. Summary of the Third Improvisation in Session 4 ........................................ 72
Table 15. Summary of the Fourth Improvisation in Session 5 ....................................... 75
Table 16. Summary of the Last Improvisation in Session 6 ............................................ 76

viii

LIST OF FIGURES

Figure 1. Change across time on Quality of Life Questionnaire ..................................... 36
Figure 2. Change across time on various components of SCARED ................................ 38
Figure 3. Change across time on SCARED total score .................................................... 38
Figure 4. Mandala drawn by the patient and his wife ...................................................... 45
Figure 5. The sheet music and the first verse from the lyric of the song “Chuck” .......... 48
Figure 6. Change across time on Quality of Life Questionnaire ..................................... 52
Figure 7. Change across time on various components of SCARED ................................. 59
Figure 8. Change across time on SCARED total score .................................................... 59

ix

CHAPTER ONE
Introduction

Most palliative care and hospice programs are concerned with the needs of the
family members of a terminally ill patient, as well as the needs of the patient (Bright,
1986; Weber, 1999). Hospice programs generally engage in meeting physical,
psychological, and spiritual needs for palliative and supportive services for both
terminally ill patients and their family members (Aldridge, 1996). This care encourages
patients to live as fully as possible and allows them to die in peace and with dignity while
surrounded by their loved ones (Aasgaard, 1999; Peters, 1987).

The findings of many researchers support the effectiveness of music therapy for
terminally ill patients and for their families in palliative care or hospice programs
(Aldridge, 1996; Bright, 1986; Bright, 2002; Gilbert, 1977; Hilliard, 2001; Hilliard, 2003;
Jackson, 1995; Krout, 2003; Marr, 1998-1999; Munro, 1984). These findings contribute
to the improvement of the terminally ill patient’s quality of life (Hilliard, 2003; Ruud,
1997) and contribute to helping family members go through this difficult time physically
and emotionally. Strategies employed include stress management, relaxation, tension
release, and anxiety reduction (Bright, 1986; Bright, 2002; Munro, 1984; Peters, 1987).

Whereas music therapy both for terminally ill patients and for their family
members is separately available and beneficial, some researchers also support the
effectiveness of music therapy intervention involving family members with a terminally
ill patient (Aldridge, 1999; Beggs, 1991; Hilliard, 2001; Martin, 1991; Weber, 1999).
Music therapy involving family members of a terminally ill patient is effective in that

singing meaningful songs can remind them of past delightful and joyful memories and

provide release and comfort during a difficult time. Family members or loved ones have
an important role in helping terminally ill patients to find meaning in their end of life
experience and to improve quality of life.

As Hilliard (2003) mentions in his study, there are many qualitative studies and
case studies regarding the effectiveness of music therapy for terminally ill patients and
their families, whereas only a few quantitative studies regarding this population exist
today. Those studies provide much information regarding how music and music
therapists can support the patients and their families.

Although many studies support the effectiveness of music therapy for a terminally
ill patient and family members of the patient, neither do those studies clearly measure the
mutual effectiveness of music therapy on the needs of both a patient and family members,
nor do they compare the effectiveness of individual music therapy with family music

therapy at the end of life of the patient.

CHAPT ER TWO
Literature Review
Terminally ill patients
Terminally ill patients have many needs physically, psychologically, socially, and
spiritually (Aldridge, 1996; Bright, 1986; Munro, 1984). Peters (1987) describes four
areas of needs of a terminally ill patient as follows:
Physical needs may include relief of acute or chronic pain and physical distress,
muscle relaxation, appropriate medication and medical care procedures to manage
medical conditions and symptoms, nutritional counseling, or assistance with
activities of daily living (bathing, toileting, grooming, eating etc.). Psychological
needs may include help in increasing or maintaining a healthy self-concept and
high self-esteem, decreasing depression or anxiety, finding ways to keep on living
to the fullest until death, facilitating expression of a board range of conscious and
unconscious feelings, having time and space to grieve or express anger,
discussing and finding ways to deal with or work through present concerns,
continuing to be involved in decision-making about one’s own life or care to the
fullest possible extent, reviewing part or all of one’s past life, finding outlets for
fantasy and creativity, and finding ways to tap and give expression to those parts
of the individual that are still vital and healthy. Social needs of individuals who
are terminally ill include physical touch, companionship, private times with
family and friends, ways to stay involved with others in meaningful activities,
links to the individual’s life before the terminal diagnosis, entertainment or

diversion from dealing with the painful reality of terminal illness, and ways to

facilitate conversations between themselves and their family members, including
discussion of difficult, emotional, or intimate issues. Spiritual needs may include
pastoral counseling, grief counseling, finding ways to express and discuss
spiritual feelings and questions, finding comfort and reassurance in religious or
spiritual beliefs, and/or rituals, obtaining support for one’s beliefs, confronting
questions about the meaning of life and what comes after death, and facilitating
the transition from life to death. (p. 358)

As some of the needs indicate above, the realization that the patient is not simply
existing, but living is crucial to increasing and maintaining the quality of life of the
patient (Bright, 2002). Several features that improve quality of life in terminal illness are
as follows: 1) Being treated as a real person with dignity, 2) AS much information about
the future as an individual wants, 3) An opportunity to make decisions regarding some
life events, 4) An Opportunity to express all kinds of feelings, 5) Participation in
meaningful human relationships, 6) Having whatever level and type of mental stimulation
that an individual prefers, and 7) Something pleasant and fun to look forward to (Bright,
2002, p. 70).

Many music therapy strategies are effective in improving each one of these needs,
as well as several of the needs at the same time, thereby improving quality of life for a
terminally ill patient. Although music therapy interventions cannot change the cause of
the pain, they can help patients change their perception of and responses to the pain. For
example, listening to individually preferred music can decrease the perception of pain
and facilitate relaxation of muscles in music assisted exercise (Bright, 1986; Munro,

1984). The music therapist helps patients to express their feelings, including sadness and

anger, and connect to their own tender feelings again through gentle music (Weber, 1999).
Recorded music is available to help reduce pain and anxiety when the music therapist is
absent, especially at night (Bright, 2002; Hogan, 1999). Despite its effectiveness, the
recorded music lacks the care and the intimacy that people can provide during a live
music performance (Hogan, 1999).

Live music performance is effective in many ways, such as in facilitating pain
relief and providing vitality, and in reducing anxiety and physical and psychological
tension (Bright, 1986; Bright, 2002; Hogan, 1999; Munro, 1984; Weber, 1999). Bailey
(1983) suggests that listening to live music promotes significantly less tension and
anxiety, and more vigor than listening to recorded music in her work with hospitalized
cancer patients. In addition, she suggests that listening to live music also provides more
physical comfort than tape-recorded music does.

Familiar and preferred songs or instrumented music can produce emotional comfort,
decrease anxiety, and facilitate verbalization regarding fears and feelings in a terminally
ill patient (Aldridge, 1996; Hogan, 1999). Singing or playing instruments can also help
maintain feelings of dignity and self-worth, motivate patients to be more independent and
to communicate with others, and increase interest in life for a terminally ill patient
(Beggs, 1991). Choosing songs or music and instruments to play provides the patients
with opportunities they can control in a situation where they frequently have no control.
In addition, the songs or other music that the patients choose can be tools to project the
feelings that the patients have, particularly, those who have a difficult time verbally
expressing things (Bailey, 1984; Bright, 1986; Martin, 1991; Munro, 1984). Song writing

helps patient express feelings, memories, and gratitude to family and friends (Bright,

2002). Musical improvisation is also a non-threatening, non-verbal tool for the patient to
express feelings and emotions. Creative music activities include singing, listening,
playing instruments, improvisation, song writing, and dance or movement to music. They
provide a patient with the time to enjoy life and live as fully as possible until the last
moment (Bright, 1986; Martin, 1991; Munro, 1984; Peters, 1987).

Some patients with terminal illnesses have deeply felt spiritual needs. For example,
religious songs or music provide some patients with comfort and reassurance, and the
music becomes a catalyst for expressing their feelings and in seeking the meaning of life
(Bailey, 1984; Bright, 1986; Bright, 2002; Munro, 1984).

Music therapists have been working in hospice settings to support the quality of
life of the individual, and many qualitative studies and case studies support the
effectiveness of music therapy in improving quality of life in terminal illness. However,
only a few quantitative studies have evaluated the effectiveness of music therapy on the
quality of life of individuals who are terminally ill.

Hilliard (2003) investigated how music therapy affected the quality and length of
life of terminally ill patients. In his study, subjects were living in their homes, receiving
hospice care, and were diagnosed with terminal cancer. They were randomly divided into
two groups. One group received routine hospice services and music therapy sessions, and
the other received only hospice services.

Hilliard found that subjects in the group that received hospice services and music
therapy sessions reported a higher quality of life than subjects in the group that received
only hospice services. In addition, the researcher showed that quality of life improved

over time when subjects received music therapy sessions. At the same time, quality of life

decreased over time when subjects did not receive music therapy sessions. This study
supported the evidence that music therapy is effective for individuals who are terminally
ill to improve their quality of life.

Family of a patient with terminal illness

Family members of terminally ill patients also suffer and need support in physical,
emotional, or psychological areas (Weber, 1999). Palliative care and hospice programs
support the family members as well as the patients during difficult times (Aldridge, 1996;
Bright, 1986). Several needs of the family members of a terminally ill patient are stated
as follows (Bright, 1986; Bright 2002; Cheng et a1, 1994; Peters, 1987; Weber, 1999): 1)
Releasing tension, 2) Reducing anxiety, 3) Being informed of the patient’s condition,
treatment, and progress of the illness, 4) Meaningful time with their loved one, 5)
Practical assistance of financial or legal matters regarding home care and funeral
arrangements, 6) Acceptance of the reality of the loss, and 7) Dealing with their grief and
sorrow.

One of the main needs of the patient’s family members as caregivers is the
reduction of stress levels due to physical and psychological distress (de Montigny, 1993;
Fuller & Geis, 1985; Hull, 1990; Vedhara et al, 2004). Many of the needs above may be
related to the cause of the stress. Song writing and lyric discussion are effective in
projecting and expressing feelings and concerns that the family members have, so that
music therapists and family members can realize what the sources of stress are and the
next step that they both can work on.

Music relaxation techniques are available and are effective in reducing physical

and psychological distress (Maranto, 1993; Pelletier, 2004; Unkefer & Thaut, 2005).

Pelletier (2004) states that music relaxation techniques are specifically effective in
increasing relaxation when the patient is under an arousal condition caused by stress. The
researcher suggests other music relaxation techniques, such as biofeedback, systematic
desensitization, hypnosis, improvisation, and music intervention based on the iso-
principle in such situations. Individually preferred music used for relaxation distracts the
patient from the sources of stress, thus increasing relaxation.

Pelletier also reported the importance of the continuation of music relaxation over
time. One result shows that individuals who have more than one music relaxation session
experience greater relaxation than those who have only one music relaxation session.
Music therapy involving family members

The need to spend meaningful time with their loved ones at the end of the patient’s
life is seen as a need of both a terminally ill patient and family members. When this
happens, it may increase a terminally ill patient’s quality of life and reduce family
members’ physical and psychological distress during caregiving.

Whereas music itself can be used as a tool to improve quality of life of a terminally
ill patient, the family members of the patient also have an important role that may
influence the quality of life at the end of one’s life. Some research suggests that music
therapy involving family members is mutually effective for a terminally ill patient as well
as family members (Aldridge, 1999; Beggs, 1991; Bright, 1986; Bright, 2002; Hilliard,
2001; Hogan, 1999; Jackson, 1995; Martin, 1991; Weber, 1999).

Reminiscence, life review, and validation of life experiences with terminally ill
patients and their families are crucial for a patient and the family (Bright, 1986; Bright,

2002; Hogan, 1999). Through reflection on their lives, achievements, failings, and regrets,

the patients can gain more meaning in what they are experiencing. Discussion of
memories helps the patients clarify their values (Hogan, 1999).

Kelly et al. (2002) investigated the wish to hasten death among terminally ill
cancer patients. The data collected in their study included the wish to hasten death, views
on euthanasia, health care experiences, impact of the illness on the patient and on others,
and the patient's satisfaction with life. The results showed that the patients with a high
wish to hasten death have more concerns with physical and psychological situations,
perceive themselves to be more of a burden to others, and experience higher levels of
demoralization.

The researchers also reported that the patients with a strong wish to hasten death
have less confidence in symptom control, less social support, less satisfaction with life
experiences, and fewer religious beliefs, than the patients who had a moderate or no wish
to hasten death. Thus, some terminally ill patients need to reflect on their lives and have a
better understanding of the meaning and value of their lives.

In addition to the clarification of life, validation of emotions of a terminally ill
patient in sessions with the patient and family together is also an important role for them,
as it helps resolve past issues and present conflicts and alleviate feelings of anxiety,
depression, and guilt.

Recognizing and expressing feelings and emotions verbally are difficult for the
patients and their family members. They may include stressful and painful topics, which
actually influence the needs of both patients and family members. Validation may occur
through music experiences. Song choice and lyric discussion through the songs can be a

positive prompt and a powerful medium in consciously and unconsciously expressing

their grief and reducing physical, emotional distress (Bailey, 1984; Martin, 1991). The
patients and their family members can often be encouraged through the song chosen by
either the patients or their family members, to discuss feelings and the topics that have
not been dealt with and to enhance their communication with those around them (Martin,
1991).

Weber (1999) noted several cases when music therapy became a bridge between
patients and their families in palliative care. When a patient was with his or her spouse,
the music therapist played music that they had enjoyed together in “good old times.” It
connected them by listening to the music together, even though they had not had much
time to do so. She also noted that often female patients are concerned about their
husbands who wonder what to do during their visiting. However, music performed by the
therapist helps fill the time and helps them calm down, so that they are relieved.

Kristjansen (1989) studied the relative rankings of the importance of various health
care provider behaviors on family caregivers of cancer patients. The majority of items
ranked were the need for prompt, attentive, and thorough medical care. Pain relief for the
patient was of the greatest importance. The researcher discussed that the family feels
more at ease when a terminally ill patient has less pain. Therefore, when music
experiences help a patient release the perception of pain, reduce anxiety and tension, and
feel more peace and with dignity, family members are also able to reduce their distress.

Bailey (1984) stated that cognitive stimulation, relationship building, singing, and
listening aspects of song experiences provide both cancer patients and their family

members with a framework for tension release, integration, and pleasure. The patients

10

and families can be aided in progress through the contact, awareness, and resolution
stages of therapy.
Mutual effectiveness of music therapy

Song experiences in music therapy with the patients and their families provide
them with support and changes. Bailey (1984) discusses that the goals of music therapy
for the patients and their family members are to promote comfort, develop meaningful
communication, and resolve issues. In addition, soothing, energizing, stimulating
expression of thoughts and feelings, and helping integrate the patients and their family
members into their social environments, providing sensory stimulation, and decreasing
pain sensation are also aimed. Towards these goals, the music therapist develops an
environment of satisfaction and trust, and this environment encourages the patients and
their family members for creative and self-fulfilling expression of their needs.

Bailey gives three stages in the music therapy process for the patients and their
family members as follows: 1) Contact (establishing trust and building the relationship
between the music therapist and the patients and/or their family members), 2) Awareness
(becoming aware of feelings, needs, and desires), and 3) Resolution (experiencing self-
fulfillment and relief, letting go issues, thoughts, and feelings). The length of time in each
stage may vary according to the needs of the patients and their family members, as well
as their willingness to actively participate.

Song experiences are effective, as the melodies and lyrics stimulate emotion and
cognition in the patients and their families. Bailey states that the patients and their family
members can communicate their needs and issues, and those needs and issues are dealt

through the melodies and lyrics. The music therapist provides the patients and their

11

family members with meaningful outlets for self-expression through identifying,
decorating, expanding song themes, and initiating new way to think and feel, so they can
experience feelings of inner peace, well-being, and relief.

Music therapy is used for meaningful interaction between patients and music
therapists, patients and patients, and also patients and their family members, at the same
time as being used in accomplishing clinical goals, such as anxiety reduction and
maintaining self-esteem and self-concept. Involving family members in music therapy
provides more positive experiences for both of them. In addition, an enjoyable experience
provides the patient with a reduction in pain perception, and it could also provide the
patient and their families with respite, so that they could deal better with the next stressful
situation (Martin 1991).

Gilbert (1977) discusses the perspectives of music therapy in dealing with the issue
of death and dying. Although terminally ill patients are willing to discuss with others
their condition to the extent that they are aware of it, their condition is not always treated
as much as the patient’s hope. Several specific concerns of terminally ill patients are
stated. One of their concerns is feeling of loneliness due to social isolation. Music
experience provides terminally ill patients with the opportunity to draw the patients closer
in the group music therapy activities.

Another need of the patients is a life review. Music activities, such as the use of
songs, assist the patients for their life review and reminiscence. In addition, the songs that
have particular lyrics in their life situations support communication between terminally ill
patients and music therapists, family member of the patients and music therapists, or the

patients and their family members.

12

Religious faith is also an important need for the patients and their family members
or loved ones. Music and lyrics provides them with a source of comfort and reassurance
during their difficult times.

The expression of feelings regarding separation from family is crucial for both
terminally ill patients and their family members. Music activities help the patients and
their families express emotions, and the patients and families can go through the stage of
acceptance of death together.

Decuir (1991) notes that the goals of family therapy are: 1) Restoration of balance
within the family, 2) Identification of systemic problems, and 3) Improvement of
interdependent functioning. In addition, improving the quality of communication within
the family helps realize these goals. One of the main reasons why creative arts therapy,
such as music therapy, is more effective than verbal methods is that because it is
nonverbal, so that the patients and their family members can more easily express their
feelings.

Music therapy is also beneficial for dying brain-impaired patients who have a
difficult time verbalizing, as it provides nonverbal musical experience to express feelings
and emotions. O’Callaghan (1993) discusses the importance of music-based family
sessions for dying brain-impaired patients in palliative care. Music-based family sessions
are the focus of her study as well as some music therapy techniques, such as musically
supported counseling, musically based life review, active participation in music activities
including music performance and song writing. She explains that these techniques help
them enhance their communication skills with people around them, especially their

family members or loved ones, despite their various difficulties, such as apathy, memory

13

problems, new learning problems, disinhibition, concrete thinking, problem solving
difficulties, and poor emotional expression.

The brain-impaired patients easily remember their favorite songs due to their long-
terrn memories, which many of these patients are relatively able to retain. As music helps
convey the important messages that are difficult to express verbally by the patients, music
therapists encourage sharing the musically evoked memories. Those memories make
positive moments of the associated events with the songs and music used and validation
of the important roles of both the patients and their family members in their lives.
O’Callaghan mentions that these experiences affirm both the patients and family
members.

Although some patients do not show any observable response, many of the patients
respond by crying, singing, delighting to their families, friends, and caregivers. In
addition, music therapy encourages family members to continue communicating with the
patients during the reminiscence and grieving process.

O’Callaghan (1996) also reports the importance of communication between the
patients and their family regarding lyric themes in song writing activities for terminally
ill patients in another of her studies. She analyzes 64 song lyrics written by 39 palliative
care patients. In those lyrics, several themes are found as follows: 1) Messages (in 56
songs, 87%), 2) Self-reflections (in 42 songs, 66%), 3) Compliments (in 32 songs, 50%),
4) Memories (in 29 songs, 45%), 5) Reflections upon significant others including pets (in
20 songs, 31%), 6) Self-expression of adversity (in 16 songs, 25%), 7) Imagery (in 11
songs, 17%), and 8) Prayers (in 7 songs, 11%). The theme “messages” implies the

importance of positive communication between them and their families, as it helps the

14

bereavement process. O’Callaghan states that those lyrics may ease the suffering of
family members or loved ones of the patients. She concludes that song writing experience
for palliative care patients provides the opportunity for expressing themes significant to
their life.

Physical touch is important between terminally ill patients and their family
members. Clair (1997) found that both the patients in last stage dementia and their family
caregivers initiated and received kisses, hugs, arms around the shoulder, and other
gestures during music activities. However, Clair notes that whereas the patients initiated
and responded to touch, their family caregivers responded less to the patients than the
patients did to the caregivers. A possible reason is that family caregivers may not
recognize that the patients are initiating touch to them. The music therapists may then
support family caregivers to realize the touch initiated by the patients and to encourage
responding.

In her case study, Jackson (1995) brings a specific example of how music therapy
was helpful to a terminal breast cancer patient in living her last moment more richly and
for her family to communicate with her during the moment. Music therapy supported the
goals for the patient to meet her and her family members’ physical, emotional, cognitive,
and spiritual needs. This patient was a musician and loved music, so music activities,
especially singing experience, became the medium to express her emotions. As she was
able to express her emotions through music activities, the patient, her family, and her
friends were connected to each other both verbally and nonverbally. Through the music
experiences, her family members felt more positive in the situation. For example, her

family felt that they were sharing and communicating with the patient, even though they

15

could not communicate verbally anymore at the patient’s last moments. Jackson also
discusses that for this family, the videotape of the patient funeral concert remained a
legacy by which to remember her.

The family members of terminally ill patients often have difficulty expressing their
feelings, as do the patients. Family members may feel frustrated, as the patients are not
able to respond in communicating with their family members, and the patients’
appearance may also be different from their last visit. Krout (2003) states that actively
expressing the feelings of grief and anguish by the family members of terminally ill
patients is normal and healthy. The music therapist provides the family members with a
meaningful experience with the patients.

With individualized interventions for the patients, music activities influence both
terminally ill patients and their family members in physical and emotional ways. For
example, the music therapist helps facilitate pain management, relaxation techniques, and
reduction of feelings of anxiety. With family members, the music activities, such as
singing or listening to familiar and favorite songs or music of the patients and their
family members, facilitate discussion of life memories, life review, and reminiscence.
The music can be then a medium to elicit emotional response and to allow the patients
and their family members to share their feelings and emotions. At this point, the music
therapist supports validation, normalization, and exploration of these feelings and
emotions from the patients and their family members. He also discusses that spiritual
needs for some patients and family should be considered, as some patients gain spiritual

strength through religious music, such as hymns.

l6

Terminally ill patients are not only adults but sometimes they are children. Fagan
(1982) discusses how music therapy influences anxiety and fear in terminal pediatric
patients. Fagan describes complacency or more often resignation as the psychological
state of terminal pediatric patients, whereas adult terminally ill patients may go through:
1) Denial, 2) Anger, 3) Bargaining, 4) Depression, and 5) Acceptance (Kubler-Ross,
1969).

In using music therapy in the treatment of anxiety and fear in terminal pediatric
patients, music therapy experience enriches the patient’s quality of life, energizes or
relaxes him or her, and provides the opportunity to express emotions in restricted, sterile
hospital environment that are associated with their lives outside of the hospital. Although
pediatric patients may hesitate to verbalize their concerns, music can help them express
their feelings and concerns with a therapeutic relationship that supplies security and trust.

Fagen mentions that music therapy may not solve the burdens of the patients and
their family, but it helps treat their anxiety and fear. As the patients and their family must
pass through their own “anxiety block,” the music therapist then facilitates this process in
an open but less frightening way. At the same time, the music therapist should wait until
the time is appropriate to discuss the patient’s needs and issues.

Hilliard (2001) discusses the effectiveness of music therapy on multidimensional
needs of hospice patients and their families through several case studies. In these case
studies, music therapy provides the support for bereavement, facilitates reminiscence,
supports pain management, modifies behavior, facilitates family interactions, helps gain

insight, and helps to come to terms with imminent death. The importance of the process

17

of music therapy is that the patients become energized or relaxed and explore their
creativity during the music activities.

Hilliard states that the ultimate goal for the patients is to have the option of
receiving music therapy, and for the music therapists to know which interventions are
most useful to the patients. For this goal, he concludes that palliative care music therapy
needs to be a research-based clinical intervention in order to best serve patients and
families.

Expression, communication, reminiscence, life review, and validation

For the needs of the patients, music therapists may consider developing a safe
environment and relationship of trust and satisfaction with the patients and their family
members or loved ones. As some researchers suggest, first of all, the music therapists
need to build a relationship with security, satisfaction, and trust with the patients and their
family members. Without this environment and relationship, the music therapists may not
be able to encourage them enough to be aware of their feelings, needs, and desires, and to
experience self-fulfillment and relief to cope with their issues, thoughts, and feelings.

In many cases, expression of feelings by terminally ill patients and their family
members is one of their needs, and it is not recognized as much as they would hope,
despite their willingness to discuss their feelings with others. As a result, the patients may
feel loneliness, and that causes social isolation. The lack of communication with their
loved ones may lead family members to have physical and emotional distress, such as
being stressed out and fatigue from the lack of sleep. Therefore, terminally ill patients
need to be able to enhance their expression of feelings and communication skills with

others.

18

As several research studies report, music therapy is effective in enhancing
terminally ill patients’ abilities to express their thoughts and feelings both verbally and
nonverbally. Although the needs of the patients are various, the studies above report that
music therapy is able to develop meaningful communication between music therapist,
terminally ill patients, and their family members or loved ones. This communication,
which occurs between them, provides the opportunity to discuss and solves their issues
when they exist, at the same time it helps increase their feelings of physical comfort and
decrease pain sensations through a fun, enjoyable musical experience.

Family members may feel frustrated during this difficult time due to a reduced
amount of communicating than the patients formerly did. However, family members of
terminally ill patients feel more positive about difficult situations when the family
members still feel able to share and communicate with the patient. Those opportunities of
expression and communication provide them with life review and reminiscence, which
are needs of the patients and their family members in validating and normalizing the
patient’s life. It is important for the patients and families to go through the stage of
acceptance of death together.

Many researchers report that specific songs or music of the patients and their
families help enhance the discussion of life memories, life review, and reminiscence. In
addition, other needs of the patients and their family members may be positively
influenced by the discussion. For example, the more they are able to communicate with
the patients, the more family members of the patients may feel relief from physical and
emotional distress as a result of the feelings of comfort which they gain through the

communication.

19

At the same time as the music therapist enhances communication between the
patients and their family members by verbal and nonverbal expression of feelings,
physical touch is also an important means in enhancing better communication between
them. As Clair (1997) notes, family members of the patients may need to assist the
patient in initiating physical touch as communication. The music therapist may need to be
careful to assure that symptoms of the patients are not missed by family members.

The music therapist provides the patients and family with the environment of
security, satisfaction, and trust. Therefore, they would have opportunities for verbal and
nonverbal expression of feelings within the music experience. These expressions
stimulate communication between the music therapist, the patient, and his family, and
also provide life review and reminiscence. The music therapist then supports them in
dealing with the issues to be resolved. This process eventually helps validate and
normalize their lives. Unknown needs of the patient and his family may be discovered,
and their other needs such as physical and emotional distress may be restored through this
experience.

Individualized music therapy plan

The literature points out that the music therapy interventions should be
individualized. Music therapists may consider who the patients and their families are,
what background they have, what kind of needs they have at that point, and how the
music therapists can support their needs. All individuals have different cultures, past
experiences, thoughts, beliefs, and moods. All patients and their families have different
musical preferences based on their life experiences. As some researchers suggest, the

music interventions, such as singing or listening to familiar and favorite music, facilitate

20

discussion of life memories, life review, and reminiscence. In particular, familiar, favorite,
or meaningful songs or music of the patients and their family members can be a bridge to
communication of their needs and issues through the specific melodies and lyrics for both
of patients and families. Those specific, meaningful songs or music can more easily
transport the patients and their family members through images of the place where they
used to be and where they can now feel the comfort and peace called “good old times.”

Spirituality of the patients and their family members is also an important aspect to
be considered individually. For certain patients and their family, music and lyrics of
religious songs provide them comfort and reassurance.

Several studies reviewed also note the importance in considering that each
terminally ill patient and his or her family members have different levels in anxiety, fear,
and stress. Each patient and his family members have unique anxiety blocks, and the
music therapist may carefully support the patient through this process in an open but less
frightening way (Fagen, 1982).

Qualitative, case, and quantitative studies

There are many research studies regarding the effectiveness of music therapy for
terminally ill patients and for their families. Those studies provide much information
regarding how music and music therapists can support the patients and their families.
However, a few research studies on mutual effectiveness of music therapy between a
terminally ill patient and his family member do exist today. Especially, not many
quantitative studies regarding mutual effectiveness of music therapy for both the patients
and their families exist, compared to qualitative and case studies. As Hilliard (2001)

suggests, even more research studies in this field documenting research-based music

21

therapy interventions may be required to optimally support, encourage, and serve
terminally ill patients in hospice and palliative care, as well as their family members or
loved ones going through difficult times.
Purpose and Problem

The purpose of this research was to investigate the effectiveness of music therapy
interventions on quality of life of the patient and stress levels of family members
involving family members of terminally ill patients in hospice. The research questions of
this study were as follows: 1) to determine whether terminally ill patients who receive
music therapy interventions with their family members show higher quality of life after a
three-week intervention, and 2) to determine whether the family members of terminally
ill patients who are involved in music therapy interventions demonstrate lower stress

levels after a three-week intervention.

22

CHART ER THREE
Method
Research design

Creswell and Piano Clark (2007) define mixed method research as a methodology
that involves collecting, analyzing, and mixing qualitative and quantitative approaches in
many aspects in the process, and also as a research method that collects, analyzes, and
mixes those data. They state that the combination of both qualitative and quantitative
approaches can provide a better understanding and better results in the research than
either qualitative or quantitative research alone. This mixed methodology also provides
more comprehensive evidence for the research problems.

Creswell and Piano Clark introduce four major types of mixed method designs as
follows: 1) Triangulation design, 2) Embedded design, 3) Explanatory design, and 4)
Exploratory design. In this research project, a triangulation design was used. The
separately collected data (quantitative and qualitative data) are merged in the
interpretation or integrated by transforming the data while it is analyzed for generating an
overall interpretation to support the research questions.

Participants

Terminal illness includes several fatal and incurable diseases, such as certain types
of cancer which has metastasized to the other parts of the body, AIDS, Alzheimer’s
disease, Parkinson’s disease, etc. (Peter, 1987). In the present study, only terminal cancer
patients were asked to participate. Cancer types could include bladder, brain, breast,
colon, endometrial, kidney, leukemia, lung, lymphoma, melanoma, non-Hodgkin’s,

ovarian, pancreatic, prostate, rectal, and skin cancer.

23

Two adult terminal cancer patients who are over 21 years old and referred by
hospice staffs were chosen from a hospice organization. One male and one female patient
were referred and the family members who participated in the interventions were their
spouses. Each patient needed to have at least one family member or loved one who was
available to visit the patient. Inclusion criteria for patients in the present study were as
follows (some of the criteria were taken from the 2003 Hilliard study): 1) The patient
resided in his or her home, 2) The patient had been notified of his or her diagnosis, 3) The
patient could verbally communicate through music therapist and his/her family member
or loved one, 4) The patient had been diagnosed by his or her doctor to survive for at
least three weeks, 5) The patient could participate in between 30and 60 minute music
therapy interventions twice a week , and 6) The patient could answer questions regarding
his/her own quality of life.

The family members or loved ones of these two adult terminal cancer patients
could participate in the music therapy intervention with the patients. Selection criteria for
the family members of the patients were as follows: 1) The family member of a patient
had been notified of the patient’s diagnosis, 2) The family member of a patient could
verbally communicate with the music therapist and the patient, 3) The family member of
a patient could participate in between 30 and 60 minute music therapy interventions twice
a week, and 4) The family member of a patient could answer questions regarding his/her

own stress level.

24

Procedures

Two terminally ill patients were referred from a hospice organization. Whereas the
patients participated in the music therapy sessions, their spouses were also involved in the
music therapy sessions. The music therapy sessions were held for each couple.

The maximum time period of every music therapy intervention was one hour.
However, the time period of every single session was flexible and could vary between 30
minutes and one hour.

Based on the needs of the patient and the family member, a music therapist
suggested the music therapy activities, even though those activities were based on the
preference of the patients and the family members and also determined by the skills of
the music therapist. The content of the strategies in the session was flexible and was
changed during each session.

The music therapy interventions were held twice a week, and the measurement and
interview were held three times a week, one at the beginning of the week and after each
of two music therapy interventions. After each music therapy intervention and
measurement, each patient had with a day for neither measurement/interview nor music
therapy intervention.

Testing materials

An experimenter-constructed instrument, a modification from several
questionnaires, including the Missoula-VITAS Quality of Life index (MVQOLI) (Byock,
1998) and McGill Quality of Life Questionnaire (Cohen et al, 1995), measured the
quality of life of the patients. This instrument included questions regarding pain, physical

problems, and psychological problems related to depression and anxiety, spiritual

25

suffering, and relationship with family and friends as well as the patients’ opinion of
whether or not the music therapy helped improve quality of life. The participants were
asked to answer each question by marking one of the five circles for either agreement or
disagreement on the question. The music therapist assisted the patients in the completion
of the questionnaire when they had a difficult time. Questions used were as follows: 1)
“How severe is your pain?” 2) “I feel Sick all the time,” 3) “I feel depressed,” 4) “I feel
anxious or worried,” 5) “I am satisfied with relationships with family and friends,” 6)
“Every day seems to be a burden or gift,” 7) “I feel more disconnected from all things
now than I did before my illness or I have a greater sense of connection to all things now
than I did before my illness,” 8) I have less of a sense of meaning in my life now than I
have had in the past or I have a better sense of meaning in my life now than I have had in
the past,” 9) “How would you rate your overall quality of life?” and 10) Music therapy
helped improve your quality of life.”

The Stressful Caregiving Adult Reactions to Experiences of Dying scale (SCARED)
measured stress level of the family members of terminal cancer patients. This is an
assessment tool for the frequency, fear, and helplessness through experiences during
caregiving. Ten potential distressing caregiving experiences were listed as follows: a)
severe pain or discomfort, b) inability to eat or swallow, or choking, c) vomiting, (1)
dehydration, e) sleeplessness, 1) falling, collapsing, or passing out, g) confusion or
delirium, and h) other, and also i) felt if “(a patient) had enough” and j) thought if “the
patient were dead when he/she was not dead.” These items were rated on a three level
scale, such as 1: once or twice, 2: every week, 3: every day for its frequency, and 0: not

frightened/helpless, 1: somewhat frightened/helpless, 2: very frightened/helpless for the

26

level of the fear and helplessness senses of a caregiver. In this instrument, a higher total
score is significantly (p <0.05) associated with greater impairment in several quality-of-
life domains, such as mental health, social functioning, energy, and general health
perceptions (Prigerson et a1, 2003).
Data gathering

Data were collected from multiple data sources that included both qualitative and
quantitative data. Qualitative data were collected from written documents (e. g.
assessment, evaluation, and progress report of a patient and his/her family member or
loved one), verbal or non-verbal response during music therapy interventions, interviews
during and after music therapy interventions, observations, and physical artifacts (e. g.
drawing, lyrics written by participants). In collecting quantitative data, questionnaire
surveys were used for measuring a terminally ill patient’s quality of life and his family
member or loved one’s stress level.
Musical instruments

Bright (2002) suggests that the instruments used in a music therapy intervention for
a terminally ill patient should be chosen according to the preference of the patient and
suitability of the instrument for this person’s capabilities. In addition, she asserts that the
therapist’s preference and skills in performance are also important. As she suggests, a
variety of musical instruments that are useful in music therapy interventions for
terminally ill patients would be made available.

The following instruments were used in the present study along with rationales for
using them. Guitar is a mobile musical instrument that can be played anywhere the

patient is situated. A classical guitar that has nylon strings may provide a softer sound,

27

whereas an acoustic guitar that has steel strings may provide a brighter sound. Electric
keyboard provides a variety of sounds and rhythm patterns for any kind of music styles.
Pressing those buttons on the keyboard is fun for many patients. Although it is not a real
piano, its mobility is greater. Sampling machine or sampler is an electronic music
instrument that not generates sounds as a synthesizer does but records or samples
different sounds, and plays back each sound. Some samplers have pads that play the
recorded sounds when pushed. Percussion instruments include shaker, tambourine,
paddle drum, rhythm stick, etc, which provide the patient with the opportunity to easily
join into the playing of music. CD Player, Tape Recorder, and Video Recorder may be
needed for any music or songs from CDs or tapes that the patient would like to listen to,
in addition to live music performance by music therapists. Besides, they can be used for
recording songs or Video for family members of a patient to keep.
Music therapy activities

Since a music therapy intervention is based on the needs of the patients and their
family members, music therapy activities in the present study needed to be individualized.
In addition, the activities that were used for each family group were different. Music
therapy strategies for terminal cancer patients included those that were more focused on
improving the physical, psychological, social, and spiritual needs of the patient in a
holistic approach (Aldridge, 1996), whereas activities only for the family members of a
temiinal cancer patient focused on stress management, tension release, relaxation, anxiety
reduction physically and psychologically (Peter, 1987). As both terminal cancer patient
and the family members participate at the same time, the music therapy interventions

were planned, combining the needs for both parties.

28

Whereas some research supports preferred music or songs by terminally ill patients
and/or their family members to help them relax and be more comfortable (Bright, 1986;
Bright, 2002; Munro, 1984; Weber, 1999), Bailey (1984) found that song themes
emphasizing hope, pleasure, the world, reminiscence, relationships, needs, feelings, loss
and death, and peace were helpful. Therefore, songs related to these themes were
prepared as well as the music or songs requested before or during music therapy
interventions. Music therapy interventions used in this research were such things as live
music performance (either by participants or music therapist, or both participants and
music therapist), song writing singing familiar or individually preferred songs, playing or
improvising on musical instruments, choosing songs and/or discussing song lyrics or
memories associated with songs, lyric discussion, and life review or reminiscence

through music or songs related to life events.

29

CHAPTER FOUR
Data Analysis

As this study used a mix method introduced by Creswell and Piano Clark (2007),
both quantitative and qualitative were individually collected and analyzed. Each data
were analyzed with the following procedures.
Quantitative data

Repeated measures analysis of variance (AN OVA) procedures compared the
experimenter-constructed scale scores regarding quality of life of each terminally ill
patient across six music therapy sessions over a period of three weeks. Only questions
one through nine on the quality of life questionnaire were compared, as question 10
(Music therapy helped improve your quality of life) in the first measurement was not
applicable as the measurement was held before the music therapy interventions. Repeated
measures ANOVA also compared SCARED scores of each spouse of terminally ill
patients across Six music therapy sessions over a three week time period. The SCARED
event scores, such as frequency, fear, and helplessness scores, were analyzed, instead of
analyzing regular SCARED total scores.
Qualitative data

Research studies need to include valid criteria to ensure rigor in the research data.
The four main criteria used to evaluate the research data were truth value, applicability,
consistency, and neutrality. These criteria are analogous to internal validity, external
validity, reliability, and objectivity in quantitative research. They may be applied in
qualitative research in naturalistic cases. However, some checks are still necessary in

terms of dealing with researcher subjectivity. There are several ways to minimize

30

researcher subjectivity, including the following: 1) Checks of the researcher’s own data
production, 2) Checks of the data by the respondents, or 3) Checks of the data by other
researchers (Smeijsters & Aasagaard, 2005).

Trustworthiness for qualitative data is described by Lincoln and Guba (1985), and
is divided into four different criteria. The criteria of credibility, dependability,
transferability, and confirmability are used in qualitative research, whereas internal
validity, external validity, reliability, and objectivity are used in quantitative research.
These four criteria can be employed to deal with researcher subjectivity.

Smeij sters (1997) offered descriptions of these four general criteria used in
qualitative research. Credibility is to make reconstructed patterns credible for participants
by describing mutuality in multiple realities. Researchers use the term “dependability” to
repeat looking at or re-experiencing thoughts, feelings, images, and so forth. In
qualitative research, the results are multiple perspectives that are replicated not the
unique treatment but the descriptions of its uniqueness. Transferability is when a research
finding can be seen to have any Similarities to findings in other cases. As objectivity used
in quantitative research is never found in qualitative research, confirmability is used as
the appropriate term in qualitative research, which includes the participants’ subjective
impressions.

Qualitative researchers also use alternative techniques to those of quantitative
researchers (Smeijsters & Van Den Berk, 1995; Smeijsters & Aasagaard, 2005). The
following alternative research techniques were used in this study: 1) Thick Description
(gathering data by containing detailed descriptions of everything that happened and was

seen in sessions, which only includes factual descriptions for multiple interpretations), 2)

31

Peer debriefing (checking for and finding out the researcher’s biases and testing working
hypotheses by asking other professionals, such as social workers, other music therapists
not involved, other researchers involved, etc.), 3) Categories (classifying the concepts
identified according to their similarity), 4) Diagnostic themes (generating diagnostic
meanings from marked words and grouping similar marked diagnostic words together),
5) Treatment proposals: (including indications, goals, objectives, music therapy
intervention techniques, etc.), 6) Triangulation (using different data sources (clients,
music therapists, researchers), different techniques of collecting data (assessment,
observation, evaluation, progress report of participants, researcher’s subjective notes,
interviews, physical artifacts), different theoretical models), and 7) Dialectical roles

(separating the roles of music therapist and the researcher).

32

CHAPTER FIVE
Case One: Tim and Mary
The clients

A 29 year old male patient who was diagnosed with cancerous brain tumors was
referred to music therapy from a hospice organization. He was first diagnosed when he
was 21 years of age. His tumor was removed, and he went through six weeks of radiation.
He remained cancer free for about seven years. When he was 26, another tumor that
could not be removed was discovered. During the next two years, he took an oral
chemotherapy pill. After a few months, he began radiation treatment again for another
new tumor.

The patient was aware of all of his diagnoses and made all decisions regarding his
treatment. According to his spouse, “He was determined to beat the cancer again and
opted for aggressive treatments.”

The patient was willingly engaged in all music therapy interventions and
interviews for three weeks until he passed away. He was able to interact with his spouse
and the music therapist by verbalizing, nodding/shaking his head, using his hand in
playing instruments, and giving “thumbs up” for expressing a positive emotion. He
participated in several different kinds of music therapy activities that either the music
therapist suggested or the patient preferred. He shared that his favorite activities were
listening to preferred music and music improvisation.

The patient’s spouse also willingly participated in all music therapy interventions
and interviews. She was open to Share anything that the music therapist asked and

supportive to the patient and was positively involved in all music therapy procedures. She

33

stated that she had especially enjoyed singing songs and song writing, through which she
expressed her emotions and feelings during the difficult time.

The assessment results in each area for both the patient and his spouse were as
follows. The patient had pain due to chronic headaches. This feeling of pain influenced
other area of his needs. He also claimed that he had not had enough rest and sleep. This
area was the primary need for the patient. Goals for the patient’s physical needs were as
follows: 1) Relief of acute or chronic pain and physical distress and 2) Muscle relaxation.
The caregiver had physical distress due to the demands of full time caregiving. She did
not get adequate sleep. Goals for the caregiver’s physical needs were as follows: 1)
Releasing tension, 2) Muscle relaxation, and 3) Decreasing physical distress. .

As the patient was not able to handle daily activities as much he formerly did, he
needed to increase and maintain his self-concept and self-esteem as well as being
provided with an opportunity for decision making. He mentioned that he felt increasing
anxiety and depression. In providing the best care for him, facilitating expression of
feelings was one of the important goals, since feelings expressed might help the music
therapist meet his needs better. Goals for the patient’s psychological needs were as
follows: 1) Increasing/maintaining self-concept and self-esteem, 2) Decreasing anxiety
and depression, 3) Facilitating expression of feelings, 4) Continuing to be involved in
decision making about his own life, and 4) Finding ways to give expression to those parts
of himself that were still vital and healthy. The caregiver stated her emotional distress
and anxiety as her main concern. Goals for the caregiver’s psychological needs were as

follows: 1) Reducing anxiety and 2) Decreasing emotional distress.

34

The music therapist set the goal for them to have more meaningful time together
when remembering past meaningful times. Goals for their social needs were as follows:
1) Provide an opportunity for life review and reminiscence and 2) Facilitate more
meaningful time together.

Both the patient and caregiver had a strong Christian faith. The following goals
were set to draw out their spirituality with music: 1) Facilitate expression of meaning of
life, 2) Provide the time for discussion of spiritual feelings and questions, and 3) Increase
feeling of comfort and reassurance found in religious belief.

Quantitative data

Change across time on Quality of Life Questionnaire is shown in Figure 1. The
AN OVA procedures revealed no differences in the patient’s quality life among the nine
questions across six music therapy sessions over a period of three weeks. Means and
standard deviations for the various measurement periods are shown in Table 1, and
Repeated Measures AN OVA on Quality of Life Questionnaire is shown in Table 2.

Change across time on various components of SCARED is shown in Figure 2, and
SCARED total score is shown in Figure 3. The ANOVA procedures revealed no
differences in SCARED score of the patient’s wife among the nine questions across six
music therapy sessions over a period of three weeks. Means and standard deviations for
the various measurement periods are shown in Table 3, and Repeated Measures ANOVA

on SCARED is shown in Table 4.

35

35

25

......
eeeeeee
uuuuuuuu
---------
----------
----------------

....................
...................................
--------------------------------------
.......................................
...........................................
...........................................
...........................................
...........................................
-------------------------------------------
..........................................
-------------------------------------------
...........................................
...........................................
.....................................
....................................
...................................
..................................
.................................
..........................

Score

..........................
........................
........................

10

cccccccccccccccccc

....................
-------------------------------------------

...........................................
...........................................

-------------------------------------------
---------------------------

..............

M1 M2 M3 M4 M5 M6 M7 M8 M9

Measurement

Individual QOL Questions

 

 

D Q10 - MT support

[II 09 - Overall QOL

3 Q8 - Meaning of life

I Q7 - Connection to things
[3 Q6 - Burden/Gift

I Q5 - Social relationship

8 Q4 - Anxiety

13 Q3 - Depression

02 - Feeling of sickness
IQ1 - Pain

 

  

________ ‘010 in M1 is not applicable

Figure I . Change across time on Quality of Life Questionnaire

36

 

Table 1. Means and Standard Deviation on Quality of Life Questionnaire

 

Mean Std. Deviation

 

Measurement 1 3.0000 1.22474
Measurement 2 3 .0000 1 .4142]
Measurement 3 3.0000 1.50000
Measurement 4 3.0000 1.50000
Measurement 5 2.7778 1 .48137
Measurement 6 2.8889 1.53659
Measurement 7 3.0000 1.73205
Measurement 8 3.1 1 1 1 1.69148
Measurement 9 3.0000 1 .65831

 

Table 2. Repeated Measures ANOVA: Quality of Life Questionnaire

 

 

Source Type IH Sum df Mean F Sig.
of Squares Square
factorl Sphericity .617 8 .077 .382 .927
Assumed

 

37

Various Components
of SCARED

 

El Hopelessness

I Fear

Frequency

 

 

 

 

 

 

 

i \\\\\\\\\\\\\\\\\\\R

 

I§\\\\\\\\\\\\\\\\S

a ,\\\\\\\\\\\\R

\\\\\\\\\\\\
1 L

 

  
  

       

 

 

 

 

L
L l
L

L

L _

       

  

    

L L L

20
5 a
10

q _
5 0

M2 M3 M4 M5 M6 M7 M8 M9

M1

Measurement

Figure 2. Change across time on various components of SCARED

 

M

M6

 

M 5
Measurement

 

 

 

 

 

 

 

 

Figure 3. Change across time on SCARED total score

38

Table 3. Means and Standard Deviation on SCARED

 

 

Mean Std. Deviation
Measurement 1 10.1667 1.25831
Measurement 2 8.0000 3.00000
Measurement 3 7.3333 3.51188
Measurement 4 6.3333 3.21455
Measurement 5 7.0000 4.35890
Measurement 6 7.3333 4.93288
Measurement 7 6.6667 5.50757
Measurement 8 6.6667 5.50757
Measurement 9 5.6667 3.78594

 

Table 4. Repeated Measures ANOVA: SCARED

 

 

Source Type IH Sum df Mean F Sig.
of Squares Square
factor] Sphericity 39.519 8 4.940 1.856 .139
Assumed
Error Sphericity 42.593 16 2.662

(factorl ) Assumed

 

39

Qualitative data

The duration of the music therapy interventions and the number of activities were
limited in each session, as the patient had pain, fatigue, and irregular sleep, due to chronic
headaches. Generally, one or two activities in a 30-minute or so music therapy session
were carried out for the patient and his wife.

Singing-along, the way of reminiscence. In sessions 1, 2, 3, and 5, the patient and
his wife chose a sing-along activity. It was a way for them to look back not only at
positive memories but also expressing feelings that they had not touched for a while.
Those songs also provided them with meaningful interaction and communication.

The song that they both hoped to sing several times was “Angel” by Sarah
McLachlan (1999), as they had positive memories of that song. The wife Shared a story
about the patient and this song in the first session. While dating for two years, they had
listened to this song so many times when they were in college. The patient first started
singing the song, and his wife joined in. The picture of them singing the song revealed
how much they enjoyed their life in college. This song might bring them back to their
youth. After the song, the wife and the music therapist sang some more songs chosen by
the wife, but the patient became quiet and closed his eyes. He might have wanted to
reflect alone. In session 2, the song was chosen again. They both made a good eye
contact with each other while singing the song. After the song ended, the music therapist
repeated the last line of the song by saying, “Hope you would find some comfort.” After
he said it, the patient and his wife quietly looked at each other, held their hands, and
smiled. Using a song to both of them enhanced meaningful communication as well as

reminiscence through the song. This meaningful communication was also seen in session

40

3 when they sang it again. But the difference was that the patient initiated holding his
wife’s hands, so the song changed his mood more in a positive direction than in the first
two sessions.

Another song was “The Rose” by Bette Midler (1979). The song was also
meaningful to them, as they had hoped to sing the song at their wedding. However, it did
not happen as their Pastor did not allow it to use for the ceremony due to some phrases in
the lyrics. While the wife and the music therapist were singing the song, the patient
quietly listened. At one point the patient commented, “That is the line why we could not
sing this song! Why didn’t he let us sing this song?” As the music therapist repeated it by
reading the lyric and it came to the last line of the song, the patient opened his mouth and
shared how he felt about that, and he became tearful. His wife who was sitting close to
him and listening gently hugged her loved one who had tears on his eyes. The song
greatly helped the patient open his heart and brought back the memory associated with
the song, which have been an emotion that he had hidden and could not express for a
while.

In session 5, after not having enough sleep and having a headache, the patient had a
difficult time engaging in the activity and often fell asleep during the music therapy
session. However, the wife chose another meaningful song that was sung at their wedding.
While the wife sang “Great is Thy Faithfulness,” the patient slightly moved his mouth
along with her, although he was half conscious. The combination of the voice of his
loved one and the meaningful song strongly and positively influenced the patient at his

bed side, despite having a difficult time.

41

Improvisation and mandala. Improvisation was one of the patient’s most enjoyed
activities that were used in the interventions and also on which produced the most active
participation, although it was used only a couple of times through the whole six music
therapy sessions. In the improvised music, he expressed his emotions by playing the
drum, which he chose quickly when the music therapist asked him to choose an
instrument.

In the first experience, the patient initiated tapping his drum, and his wife joined in
him by playing an egg shaker along with his beat. The beat dramatically changed
between slow and fast with different dynamics as he tapped and scratched. The patient
explained after the music ended that he expressed quietness with the scratch sound and
loudness with the tapping sound. The patient stated that he experienced randomness
while his wife said she felt intense during the music. Even the first time they played, the
patient, the wife and the music therapist carefully listened intently to each other’s sounds.
Later, the patient shared that he experienced the feeling of “working together” in the
music.

In the next improvisation, the patient remained with his drum while his wife chose
the keyboard, and the music therapist chose to play the guitar. In this experience, the wife
was more the lead in the music as she played and repeated the melody in D-minor within
its pentatonic scale. During this time the patient was quietly repeating one beat on his
drum. After the music ended, the music therapist asked the following three questions: 1)
“What adjective would be appropriate for the music?” 2) “What color they felt in the
music?” and 3) “What emotion they felt in the music?” The patient stated that the music

was intense and he felt it was orange that was divided into red and yellow as the music

42

moved on, but he stated that he did not emotionally feel anything during the music. The
phenomena the patient experienced is known as chromesthesia or synesthesia, which is
when hearing music stimulates a visual sensation of color. On the other hand, his wife
stated that she could not come up any adjective for the music that they produced, but she
felt the colors gold and red that were close to the color the patient experienced. She
expressed her emotion as happy during the music (see Table 5).

As the patient and his wife might be able to express more visually, the music
therapist asked them to draw what they just experienced and felt in the improvised music.
The music therapist provided them with a paper including a circle in the middle of the
paper, which is known as a mandala. They did not need to think anything of what to draw
together and did not need long to finish. As they drew together, the patient only drew
within the circle making red, orange, and yellow random lines. His wife drew trees,
leaves, shiny sky, and feathers only outside the circle (see Figure 4). She explained, “It
was just a way to express the sensations the music evoked in me, such as the warm and
bright colors and the feeling of the forest and the sun shining down on the leaves
covering the ground.” The patient’s random lines give the impression of confusion that
remained within such a limited space to move, while his wife surrounded him with such a
warm and bright color image. She explained regarding this drawing after the patient
passed away, “Now that picture means the world to me. Tim wasn't a very artistic person

and now I have this drawing he helped me do and will always remember that.”

43

Table 5. Summary of Improvisation in Session 1

 

 

 

Music Therapist (MT) Patient (PT) Spouse (SP)

Encouraged PT to pick

up a percussion

instrument:

tambourine, egg

shaker, small size drum

Picked a tambourine Chose a drum quickly Chose an egg shaker
Initiated playing the
drum by tapping and

Asked adjectives
would be appropriate
for music just played
Asked for next
improvisation

Chose guitar

Asked adjectives,
color, their emotions

Asked PT and SP to
draw a mandala
together, and provided
a paper that had an
empty circle in the
middle

 

scratching it. He stated
later he expressed
loudness and quietness
Said “Randomness”

Chose a drum again

Adjective -- intense,
Color — orange (this
orange became divided
into yellow and red
eventually)

Emotion — None
Shared he felt PT, SP,
and MT collaborated
well to make the music
Only drew within the
circle

Drew yellow and red
colored random lines
inside the circle

 

Said “Intense”

Chose keyboard and
played pentatonic scale
as the MT put the
colored tapes on F and
B to not play

Started playing with a
melody in Dm
Adjectives — None,
Color — gold and red,
Emotions — happy

Worked outside the
circle

Drew trees, shiny sky,
leaves, feathers (blue
and red)

 

44

 

 

Ht. ...
. 15.5.05. 4.,

O

.r.
.. L t
k} .5

 

Figure 4. Mandala drawn by the patient and his wife

An image in this thesis is presented in color

45

Song writing, memories and distraction. Although the patient physically had a
difficult time participating in each activity, both the patient and his wife collaborated to
write their own song as a legacy. They willingly accepted this activity. The music
therapist asked them to think of any topic and keyword for the song in session 1 to make
the activity easier. At the next visit, they shared the topic and keyword that they had been
discussing for the song writing. The word shared by the patient and his wife was
“Halloween,” and the patient continued that the keyword of this song was a guy named
“Chuck.” The wife stated, “When Tim first picked the topic for the song as Chuck with
the memory of that Halloween party and our friend's costume I didn't think it could
possibly make a good or interesting song. I just couldn't see it. As we worked on it and
the lyrics fell together I began to see what he could see, this vision for getting that hilarity
across. And again it was neat to see him in that creative process.” This imaginary
character was acted by one of their close friends on Halloween three years ago before the
music therapy sessions began. They brought up such a positive image in the midst of their
difficult times. However, it was a way for the patient to visualize his image in a creative
way. In addition, this activity supported the wife not only in expressing her feelings but
also to release her stress, when she shared with the therapist that at that time she did not
have another outlet to express her feelings.

They already wrote half of the lyrics at that time, and expressed their emotions by
smiling when they shared the lyrics they wrote. This shows how much they enjoyed
working toward something fun and working together, and also how this imaginary

character had remained a positive and meaningful memory to them.

46

The patient participated in this activity with suggesting and agreeing what the wife
came up with on the lyrics and on the keyboard when she tried to make a melody. In the
last session, the patient’s condition was not conductive to do this activity as he had lost so
much sleep and had a headache, but he was still willing to participate in song writing by
deciding chord progressions for the melody written by the wife. The music therapist
supported the patient with using the sampling equipment including several useful chords
of F-Major played by piano, such as F-Major 7, D-minor 7, C-Major, Bb-Major 7, A-
minor 7, G-minor 7, G-Major 7, etc. By pushing the pads on the sampling equipment, the
patient was able to decide the chord progressions. Although this activity had not been
finished within the whole six music therapy sessions, the wife agreed to finish the song
writing as a memory of her loved one and a meaningful activity that they started working
on together before the patient passed away. Later the music therapist visited the wife to
continue the song writing. The song (see Figure 5) is the one completed by the wife after

the collaboration with her husband.

47

Chuck

 

The door swung op-enand start-ding,__ There_ was a

Dm7 G7 Dm7 Em7

 

tall dark su-oueaewim s-fro_ hair._ He stepped out of the night_ and_ in-

A7 BbM7 A7

 

- to the light_ and that‘s when I could see, He wore

Dm7 Cm7 F7 BbM7 C7

 

plat - form shoes sndblack bell - bottom pants_ flar-ing at the knee—

Drn7 Cm7 F7 Gm7 C7

 

Dm7 Cm7 F7 Gm7 C7

         

long sleeved shrrt_ with wide la - he thought looked best The

Dm7 G7 61:17 C7 Dm7 Dm7 G7

 

tsgonhisshirtsaid "HimynsmeisChuck"Thetagsaid Chuck Chuck mynsmeis

Dm7 Dm7 G7

         

Chuck The tag said Chuck Chuck my name is Chuck

Copyright © All Rights Reserved

Figure 5. The sheet music and the first verse from the lyric of the song “Chuck”

48

CHAPTER SIX
Case Two: Betty and James
The clients

A 76 year old female patient diagnosed with lung cancer was referred to music
therapy from a hospice organization. She was an independent person who was active in
doing most of her daily routines, such as cleaning her room and cooking. She enjoyed
meeting new people and doing new things. She stated that she sometimes had pain.
However, her pain was controlled by medication that she took whenever she felt pain.
Coughing also sometimes made her uncomfortable, although she was able to control it by
taking cough drops.

The patient was referred to music therapy due to her past musical experience. It
was thought that she could be passionate about the experience, so music therapy might
help support her and help improve her quality of life at the end of her life. According to
the patient’s daughter, who visited the patient everyday, she had had been away from the
music that she always enjoyed through her life. Although she used to play the organ and
always enjoyed singing and listening to music, the only musical activity that she was
usually able to participate in was singing during the service at her church, where she
attended regularly. The patient was always eager to try new activities that the music
therapy introduced, such as improvisation and writing lyrics using a fill-in-blank
technique.

The patient’s husband who was a full time caregiver also willingly participated in
all the music therapy interventions, although he showed some hesitation to participate. He

was friendly, supportive, and caring toward both his wife and the music therapist. He

49

displayed a positive attitude toward music therapy, as he knew that music had been a big
part of his wife’s life, so it had the potential to make her life richer at the end. He had had
a hard time accepting the reality that his wife would be gone and physically separated
from himself.

Despite his hesitation to initiate sharing, the caregiver was open to share when he
was asked. He made jokes during the interventions, as he shared that he would like to see
and offer support for whatever made his wife happy.

The assessment results for both the patient and her caregiver were as follows. The
patient was able to control her pain with medication provided by her doctor. She also
used music (e. g. listening to the radio) for her relaxation. Goals for the patient’s physical
needs were as follows: 1) Release muscle tension, 2) Learn music relaxation technique
for when music therapy is not available, and 3) Decrease or be distracted from the feeling
of pain. The caregiver was able to relax himself by talking with the patient, listening to
radio, etc. He stated that he did not have distress as long as the patient looked fine,
although he might feel distress and physical tension when he saw that the patient had a
difficult time, such as expressing pain and coughing. Goals for the caregiver’s physical
needs were as follows: 1) Release muscle tension and 2) Learn music relaxation
techniques for when music therapist is not present.

Although the patient occasionally experienced anxiety that made her depressed, she
was able to control her anxiety with medication provided by her doctor, so she did not
have any confusion during the music therapy intervention. Goals for her psychological

needs were as follows: 1) Facilitate expression of feelings, 2) Decrease anxiety and

50

depression, 3) Maintain a feeling of well-being, 4) Facilitate expression to those parts of
the individuals that are still vital and healthy, and 5) Be involved in decision making.

The caregiver stated that he did not have much anxiety, since the patient’s anxiety
was controlled. Plus he did not feel any emotional distress and anxiety as long as the
patient did fine. However, he was hesitant in expressing his feeling. The goal for his
psychological needs was to facilitate expression of feelings.

The patient stated that she was satisfied with relationships with her family and
friends. However, she shared that she always wanted somebody to talk with other than
her husband living with her. The caregiver needed meaningful times with the patient.
Goals for their social needs were as follows: 1) Provide an opportunity for life review and
reminiscence, 2) Facilitate conversation and discussion of any difficult, emotional,
intimate issues when they exist, and 3) Facilitate more meaningful time together.

Both the patient and the caregiver had a strong Christian faith. Whereas the patient
felt her life was a gift, she felt that she had less of a sense of meaning in her life than
before the illness. Goals for their spiritual needs were as follows: 1) Facilitate expression
of meaning of life, 2) Provide time for discussion of spiritual feelings and questions, and
3) Increase feeling of comfort and reassurance in religious belief
Quantitative data

Change across time on Quality of Life Questionnaire is shown in Figure 6. The
mean on descriptive statistics Showed that the patient’s quality of life level improved over
the time of the music therapy intervention (p < .000) (see Table 6). Repeated Measures
AN OVA on Quality of Life Questionnaire were shown in Table 7. Pairwise Comparisons

were run using the Least Significant Difference (LSD) test. This showed that there were

51

significant changes between measurement one and nine (p < .023), two and nine (p
< .023), three and nine (p < .022), four and nine (p < .013), five and nine (p < .013), six

and nine (p < .013), seven and nine (p < .013), and eight and nine (p < .013) (see Table 8).

60

50 Individual QOL Questions

DQ10 - MT support

1]]Q9 - Overall QOL

E Q8 - Meaning of life

I Q7 - Connection to things
[2] Q6 - Burden/Gift

I Q5 - Social relationship
Q4 - Anxiety

El QS - Depression

Q2 - Feeling of sickness
I Q1 - Pain

 

40

Score
C»)
O

20

 

 

 

*Q10 in M1 is not applicable

 

O .
M1 M2 M3 M4 M5 M6 M7 M8 M9
Measurement

Figure 6. Change across time on Quality of Life Questionnaire

52

Table 6. Means and Standard Deviation on Quality of Life Questionnaire

Table 7. Repeated Measures ANOVA: Quality of Life Questionnaire

 

 

Mean Std. Deviation
Measurement 1 4.2222 .83333
Measurement 2 4.2222 .83333
Measurement 3 4.3333 .7071 1
Measurement 4 4.4444 .52705
Measurement 5 4.4444 .52705
Measurement 6 4.4444 .52705
Measurement 7 4.4444 .52705
Measurement 8 4.4444 .52705
Measurement 9 5.0000 .00000

 

 

 

Source Type III Sum of (If Mean Square F Sig.
Squares
factor] Sphericity 3.778 8 .472 5.667 .000
Assumed
Error Sphericity 5.333 64 .083
(factorl ) Assumed

 

53

Table 8. Quality of Life Comparisons

 

 

(I) (J) Mean Std. Sig.(a) 95% Confidence Interval
factorl factorl Differenc Error for Difference(a)
e (H)
1 2 .000 .000 .000 .000
3 alll .111 .347 a367 .145
4 n222 .147 .169 n56] .117
5 n222 .147 .169 n56] .117
6 a222 .147 .169 2561 .117
7 n222 .147 .169 n56] .117
8 2222 .147 .169 a56l .117

 

 

f ‘ 9 "ZTZW (*)"“"‘""“‘"‘§“.27 "‘""“‘"".023 4.41? 41? -'

   

 

2 1 “"000 " J 000 000
3 all] .111 .347 n367 .145
4 a222 .147 .169 a56l .117
5 n222 .147 .169 n56] .117
6 n222 .147 .169 a561 .117
7 n222 .147 .169 n56] .117
8 n222 .147 .169 n56] .117
9 -.778(*)“ 1278' .023 141's ".137“;

 

 

 

54

Table 8 (Continued)

 

.1 11 .111 .347 -. 145 .367

.111 .111 .347 -.l45 .367

-.l 11 .1 11 .347 —.367 .145

-.l 11 .111 .347 -.367 .145

-.1 ll .1 11 .347 -.367 .145

-.1 11 .111 .347 -.367 .145

-.1 11 .111 .347 -.367 .145

 

‘-.667(*') * .236 .022 41.210 -.l23 1
.222 .147 .169 -.l 17 .561
.222 .147 .169 -.117 .561
.1 11 .111 .347 -. 145 .367

r21.“ H D7}L\t'-3-.“€ '5. in). ’1 ' UL'RJLE T 1.?qu :3: .I....“!. _-a.' ‘ .2. '11—?” t ._ 9m .IA . II: ".n .- humane—2.1 in: .. at)”; mug-Afi- J-wel'il 'nhbjh .m'flmu" -'.'-\_"."'J-_T.| Iv_.- :q
‘ E
"I — - - u
1. e I e s e i
I
I
r

——E L—’. ‘3: ' -',' ' r, 7 . L-; .57 r L ‘ 7: :7 7 .::’ 54-: 7713* :7,* :L , ' ' ‘ 27; . F'L'JiL‘

_-_ ,-ee _. .7 7 _- *4 :—~r _ - » ’52:.3" __ El

55

Table 8 (Continued)

 

Fargo-vanes“
I r,
i

I, «are:

.222

.222

.111

.000

.147 .169 -.117

.147 .169 —.117

.111 .347 -.145

.561

.561

.367

 

1‘76"" 013 :96] ,
”.1747 .169 117
.147 .169 -.117

.111 .347 -.l45

 

_......:.:.556(*).4 s .. -_..

. g...—

56

 

 

176'“ “ ‘ .013 "4.961

Table 8 (Continued)

 

 

 

.222 .147 .169 -.117 .561
.222 .147 .169 -.117 .561
.111 .111 .347 -.145 .367
.000 .000 .000 .000
f 4.5566) .176 .013 -.961 :.150 if
1... .41
.222 .147 .169 -.117 .561
.222 .147 .169 —.1 17 .561
.111 .111 .347 -.145 .367
.000 .000 .000 .000
" 355675?) 176 ' "101“?” 3.981 -.'i"5""6"' "

 

 

57

Table 8 (Continued)

 

Based on estimated marginal means
* The mean difference is significant at the .05 level.

a Adjustment for multiple comparisons: Least Significant Difference (equivalent to no adjustments).

Change across time on various components of SCARED is shown in Figure 7, and
SCARED total score is shown in Figure 8. Repeated measure ANOVA procedures
reported that significance on SCARED score of the patient’s husband. The mean on
descriptive statistics showed the spouse’s stress level decreased over the time of the
music therapy intervention (p < .000) (see Table 9). Repeated Measures AN OVA on
SCARED was shown in Table 10. Pairwise Comparisons were run using the Least
Significant Difference (LSD) test. This showed that there were significant changes
between measurement one and four (p < .020), one and five (p < .015), one and six (p
< .015), one and seven (p < .032), one and eight (p < .032), one and nine (p < .020), three
and seven (p < .020), three and eight (p < .020), three and nine (p < .015), and four and

nine (p < .038) (see Table 11).

58

Various Components
of SCARED

DHopelessness I

I Fear
Frequency

 

 

 

 

 

 

 

    

 

 

  

 

  

 

 

L .fi

LSSSS
. L I.
L L S
LL . SSS
.. L LL
LLLISSSS
.L.uLS\\\\S\\S
L. S
L L_ L
_.a SS
"L
: LSSSSSSS
eapeeeree

900%

M2 M3 M4 M5 M6 M7 M8 M9

1

M

Measurement

Figure 7. Change across time on various components of SCARED

 

 

 

 

 

 

Measurement

Figure 8. Change across time on SCARED total score

59

Table 9. Means and Standard Deviation on SCARED

 

Mean Std. Deviation

 

Measurement 1 5.3333 2.51661
Measurement 2 5.0000 4.00000
Measurement 3 4.0000 2.64575
Measurement 4 3.0000 2.64575
Measurement 5 2.6667 2.08167
Measurement 6 2.6667 2.08167
Measurement 7 1.6667 2.88675
Measurement 8 1.6667 2.88675
Measurement 9 1.3333 2.30940

 

Table 10. Repeated Measures AN OVA: SCARED

 

 

Source . . Type III Sum df Mean F Sig.
of Squares Square
factor] Sphericity 50.963 8 6.370 10.269 .000
Assumed
Error Sphericity 9.926 16 .620

(factorl ) Assumed

 

60

Table 11. SCARED Comparisons

 

 

(I) . (J) Mean Std. Sig.(a) 95% Confidence Interval
factor] factor] Differenc Error for Difference(a)
e (LI)
1 2 .333 .882 .742 -3.461 4.128
3 1.333 .333 .057 -.101 2.768

-.333

1.000

2.000

2.333

2.333

3.333

3.333

3.667

.882

1.000

1.000

1 .202

1 .202

1 .202

1 .202

1.333

.742

.423

.184

.192

.192

.109

.109

.111

-4.128

-3.303

-2.303

-2.838

-2.838

-1.838

-l.838

-2.070

 

3.461

5.303

6.303

7.504

7.504

8.504

8.504”

9.404

 

61

Table l 1 (Continued)

 

U’I

-1.333

-1.000

1.000

1.333

1.333

 

2 2.000
3 -1000
5 .333

6 .333

7 1.333
8 1.333
9 ‘“ 1.66

.333

1.000

.000

.333

.333

1.000

.333

.333

.333

.333

62

.057

.423

.057

.057

.184

.423

.423

.057

.057

-2.768

-5.303

1.000

-.101

-.101

-6.303

-1.000

-1.101

-l.101

-.101

-.101

.10]

3.303

1.000

2.768

2.768

 

2.303

-1.000

1.768

1.768

2.768

2.768

 

Table l 1 (Continued)

 

 

 

 

f 1 '121667(*)' 1333- .015 4TH -1232 ‘1
TM” 2 —2.333 1.202 1192"““7-7 504 "273—38 '-

3 -1333 .333 .057 -2.768 .101

4 -333 .333 .423 -1.768 1.101

6 .000 .000 .000 .000

7 1.000 .577 .225 -1.484 3.484

8 1.000 .577 .225 -1.484 3.484

9 1.333 .333 .057 -.101 2.768
[“6“ ””1““ 2667(T)" .333 “““ .015’“ '-4.101 4232“]
L—T" 2 2333 1.202 I192“ * 571304 ""2838

3 -1333 .333 .057 -2.768 .101

4 -333 .333 .423 -1.768 1.101

5 .000 .000 .000 .000

7 1.000 .577 .225 -1.484 3.484

8 1.000 .577 .225 -1.484 3.484

9 1.333 .333 .057 -.101 2.768

 

63

Table l 1 (Continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

7 -3.667(*) .667 .032“ = ’

-3.333 1.202 "109"

2333(5) .333 .020 3.768“ .1899

1... "717.333 3.3.3. “.0573-.. 282.768” __ _ _ _. .101." .4
-1000 .577 .225 -3.484 1.484
-1000 .577 .225 -3.484 1.484
.000 .000 .000 .000
.333 .333 .423 -1.101 1.768

' 8 1336777) “' "667”” 7032" 36.535 “3798—"

1.. " ' 3333 1.202 .109 18.504 7 1.838 i

r” ” -2.333(*) .333 .020 3.768 -.899 ‘

L“ r -1333 .333 .057 -2.768 T .101 i
-1000 .577 .225 -3.484 1.484
41.000 .577 .225 -3.484 1.484
.000 .000 .000 .000
.333 .333 .423 -1.101 1.768

 

64

Table l 1 (Continued)

 

3' '9‘ ' ’1 4.00001) '37‘7 .020 "26.484 ""‘1'1‘.5T6"“
L _ _" 2"”"W13367”"" ’ "11333 ."11i‘" ”497101W"”"27070‘J
" 3 -2.667(*) .333 .015 ' —4’fi01 -1232
4 -1.667(*) .333 .038 -3101 -232
L ' “M"3"““Wl'if333”" "‘.333"""’"‘ .057" W “-2.768“ 7101”“
6 -1333 .333 .057 -2.768 .101
7 -333 .333 .423 -l.768 1.101
8 -333 .333 .423 -l.768 1.101

 

Based on estimated marginal means
* The mean difference is significant at the .05 level.

a Adjustment for multiple comparisons: Least Significant Difference (equivalent to no adjustments).

Qualitative data

Through the whole six music therapy sessions, the patient willingly participated in
all activities that both the music therapist suggested and the patient preferred with singing
along, improvisation, song writing (fill-in-blank), and playing instruments. The patient
stated, “I like music! I like singing and used to play organ!” at the first visit, and she
showed so much eagerness toward the music activities whenever the music therapist
visited. Her husband was slightly hesitant to participate in the activities at the first music
therapy session. However, the more the music therapist visited them, the more he enjoyed
the activities and enjoyed watching his wife enjoying and the more the husband became

open to share and express his true feeling about what was happening around him.

65

A lot of smiles and laughter were seen in session 1 through 4 while they sang songs,
played instruments, and shared fun stories that they had experienced. This result may
indicate that the patient and spouse simply enjoyed music therapy and how much music
had been a big part of their lives.

Dancing as remembering good old days. In session 1, the patient was excited about
telling the music therapist how much she enjoyed music and how it was such a big part of
her life, as she shared that she had liked singing hymns at church and any other songs for
fun, playing the organ, and listening to the radio since she was young. In addition, she
shared that she used to dance with her husband. Although the husband often hesitated to
dance with her, once they held hands as they moved along with the CD recordings that
they chose to play, increased their eye contact, and expressed their emotions by smiling
and laughing. This activity enhanced not only a fun experience but also served as a
reminiscence of how they shared their experience of dancing when they were younger.
Dancing brought them back to the good old days, and it improved quality of life for both
of them.

Outside music therapy interventions. The music therapist recorded a tape that
included several old time popular music, hymns, and so forth, for the couple. This tape
was originally made as a relaxation induction for the patient when the music therapist
was not available to distract her from her pain and discomfort. However, one of their
children mentioned that the patient sang and danced along with the tape. The daughter
showed her appreciation for music therapy as she was able to see her mother looking very

happy, which had not been seen for a long time.

66

Singing-along and fill-in-blank to express happiness. The patient and spouse
preferred a singing along activity in all sessions. She was always willing to participate in
the activity not only with singing along, while she expressed her emotion by smiling and
laughing but also with choosing songs to sing. When the music therapist asked the patient
and spouse to choose songs from a songbook provided by the music therapist, she tended
to pick up the songs that included the word “happy” or “happiness,” or the songs that
made them feel happy, such as “Happy Days Are Here Again” and “You Are My
Sunshine.”

“I Want to Be Happy” is one of the songs that the patient chose to sing many times.
She said, “I’m in the mood for this song!” in session 3. In session 4, the spouse who was
very quiet during the sessions said, “That’s right!” with a big voice and smile when the
music therapist read and repeated the lyric “I want to be happy, but I won’t be happy till I
make you happy, too,” and the patient smiled at him. In session 6, the patient chose
“Happy Days Are Here Again” and stated that she wanted to sing a song about happiness.
After singing the song, the patient said, “I didn’t smile very much before and after my
surgery, but I do now so it makes my children happy.” One of their children mentioned
that the patient had had low spirits, and she was not as active as she used to be after she
had surgery for her illness. However, music therapy and music itself brought such a joy
back into her life. The reason why the patient chose those songs may be because she
wanted to be happy and she hoped that happy days were there to her again.

The music therapist used fill-in-blank techniques to help them more express their
emotions. When the spouse chose a song “Carolina in The Morning,” the music therapist

asked them to fill in the following blank with their own words, “If you had Aladdin’s

67

lamp for only a day, what would you like to do and ask for?” The patient said, “I’d make

'39

a wish to have a good time with honey in a sunny day The spouse responded to her by
saying, “I’d make a wish to make her happy,” and they both laughed looked at each other.
In session 4, while singing “You Are My Sunshine,” the music therapist asked them to

fill in the following blank as if this “You” was their spouse, “You are my sunshine, my
only sunshine. You make me happy when?” The patient said to the spouse, “When you
are with me and when you love me!” The spouse responded to her, “You make me happy

’9
!

all the time This activity helped them not only verbally express their feelings but also
recognize and confirm how they felt about each other. “Happy” or “happiness” was a big
keyword that both the patient and spouse repeated in all sessions.

What happened at this point was important in positively affecting both the patient
and her husband. The patient was able to positively express her feelings through singing
her preferred songs and smiling and laughing, and her husband smiled back to her as he
was happy about what was happening in front of him while he watched the patient
looking happy. This positive influence also went back to the patient again and provided
her with even more positive experience.

Happy ending with family in improvised music and life. Improvisation also
provided for both the patient and her husband such an effective environment to express
their emotions and thoughts. In session 2, they experienced the first improvisation
activity. The music therapist provided them with no theme to express and asked them to
play anything that they felt, so they had freedom to express whatever was on their minds.

The patient and her husband started playing a random rhythm pattern with their

instruments while they did not look at each other. It was as if they had no idea where they

68

were, so they wandered seeking what they needed to know. The patient explained that
they experienced several different emotions in the improvised music. The random rhythm
patterns included soft, quiet, mysterious, serious, exciting, and happy that order. When
they expressed “exciting” and “happy” with a loud sound toward the end, they increased
eye contact and the music suddenly stopped. The patient stated that it was a happy ending
and her husband agreed with her opinion. The patient also stated that this happy ending
meant family to her and explained that the ending was accomplished with her husband’s

support (see Table 12).

Table 12. Summary of the First Improvisation in Session 2

 

 

Music Therapist (MT) Patient (PT) Spouse (SP)

0 Asked PT and SP to o Chose a tambourine 0 Chose a hand drum
pick up any 0 Played a big loud sound 0 Played a big loud
instruments and play it at the end and the sound at the end,

music was suddenly making eye contact
stopped while making with PT
eye contact with SP

0 Asked how they felt in o Experienced several . o Stated that he felt the

improvised music different feelings in same way as PT felt

music, soft, quiet,
mysterious, serious,
exciting, and happy in
order

0 Stated that she felt that
the ending was like a
big happy ending
(smiling and laughing
when making the

 

 

 

ending)

0 “The ending of music 0 Quietly listened to PT
means family! ”

0 “James was very
supportive! ”

 

 

69

In session 3, the music therapist provided the theme for them to play, “sadness”
and “happiness.” As they already had experienced improvisation once, it was not difficult
for them to get into the place to express. They expressed “sadness” with a random rhythm
pattern without making eye contact. They stated that the random rhythm meant sickness
to the patient and seeing the patient who was sick to her husband. They did not look at
each other when making the rhythm, as if the patient tried not to show her being sad and
tried not to see her husband and how he might feel. The same thing might have happened
to her husband as he made also different kind of random rhythm pattern from that of the

patient without making eye contact (see Table 13).

Table 13. Summary of the Second Improvisation in Session 3

 

 

Music Therapist (MT) Patient (PT) Spouse (SP)

0 Asked PT and SP to 0 Choose a tambourine 0 Choose an egg shaker
pick up any
instruments

- Encouraged to express 0 Played random 0 Played random
“sadness” “happiness” patterns, without patterns, without
in music and start with making an eye contact making an eye contact
“sadness” with SP with PT

0 Gave a verbal cue to 0 Looked at SP and 0 Looked at PT and
switch from “sadness” matched the pattern matched PT’s pattern
to “happiness” with SP’s pattern

- Asked PT and SP what 0 Answered “Being 0 Answered “Her (PT)
the sadness expressed sick.” being sick.”
in music meant to PT
and SP

0 Asked PT and SP what 0 Answered “Family.” 0 Answered “Her (PT)
the happiness being happy.”
expressed in music
meant to PT and SP

 

 

 

 

 

7O

In contrast, they expressed “happiness” with a matched rhythm pattern. When they
were asked to make a “happiness” rhythm, they looked at each other, so they could adjust
the pattern. The keyword “happy” and “family” were expressed again (see Table 12 and
13). Happiness meant family to the patient as having support by her husband and other
family members, and meant watching the patient being happy to her husband. This
opportunity for them to verbally express their feelings of how they felt about happiness
brought them closer together. Normally the husband had a difficult time expressing his
feelings to the patient.

Scary, sad, and support by family. Specific discussion of the experience of anxiety
and sadness occurred in sessions 4 and 5. The patient and her husband quietly improvised
a slow, random pattern. The patient stated that she had a scary experience in the
improvised music, although she was able to escape from the experience at the end. The
music therapist suggested her husband to match the rhythm with the patient’s pattern
while the patient played the exactly same pattern as the one previously played. The
patient experienced her husband’s support in the second improvisation as she stated that
he saved her from the scary experience and guided her to not get lost. In this experience,
the husband changed his instrument to match the rhythm pattern played by the patient,
which might mean that he tried to find different way for the patient to not feel scared. His
support in the music made a difference in the patient’s experience in the improvisation
(see Table 14).

Projecting life experience and emotion deep inside in music. The improvisation in
session 5 was the point when the couple was able to even more deeply express their

emotions. “Sadness” and “Happiness” were expressed separately in the previous

71

improvisation sessions. However, the patient and her husband were not only able to
express their feelings that they experienced in the improvised music but also more able to

connect or associate those experiences in music with experiences in their real life.

Table 14. Summary of the Third Improvisation in Session 4

 

Music Therapist (MT)

Patient (PT)

Spouse (SP)

 

 

Encouraged to express
their feelings in
improvised music

Asked to explain the
sound that they played
in improvised music

Asked PT and SP to
play exactly same
rhythm that PT had
just played and
suggested SP to play
with PT

Asked to how they felt
in the second
improvised music

 

Played a slow, random,
quiet sound with her
drum and the sound
became loud noise

“I was walking on the
road alone. Nobody
was there. Someone or
something was chasing
me, so I was scared. I
tried to run away from
the thing that chased
me. At the end, I was
able to escape from
there.”

Chose the same drum

Stated that she really
felt that SP supported
and saved her in the
scary situation that she
experienced in the
previous improvisation
Also stated that SP
came with her and led
her to not get lost, so
she did not feel scared
at all in the second
improvised music.

 

Played a relatively
soft, inconsistent
sound with his
tambourine

Changed his
instrument from a
tambourine to an egg
shaker and matched
the pattern with PT’s

 

72

 

“The sound at the bottom makes me sad, and I didn’t want to stay there, so I went
up, but still went down and up again. I sometimes go into a bad mood because of illness,
but I don’t want to give up fighting and give up on my health.” This comment was made
by the patient immediately after the patient and the music therapist improvised a random,
dissonant melody going up and down on the keyboard, as the music therapist asked if
they could express “illness” in music. She projected and analyzed the melody herself as
precisely what she had been experiencing in her life. At that time, her husband listened to
the patient’s melody carefully and matched his drum with her sound. The patient
mentioned that she felt his support in the music, so she was able to end the music with a
happy ending again. She continued to say that she was able to fight with her illness with
his support and encouragement and able to feel happiness in her real life. The
“happiness” meant going to heaven, meeting God, and having no pain any more as well
as being surrounded by her family, which she expressed in the other activities. While the
patient shared her feeling, her husband looked down and quietly listened to her without
smiles. The music therapist also asked him the same question (see Table 15).

Despite this positive comment made by her husband as he stated, “As long as she
looks happy and alright, I’m happy and I’m not worried,” his facial expression was the
opposite and he became emotional. He had a difficult time accepting her illness and what
was going to happen to her, although he was told by the hospice staff. After he said that
he would accept whatever God was going to do for the patient, he had tears on his eyes
and the patient quietly looked at him. The improvisation in this session strongly assisted

both the patient and her husband to go deeper inside their feelings, open the feelings up,

73

and extemalize them. It also enhanced communication between them as they verbally
shared how they really felt.

In session 6, which was the last session, the music therapist asked only husband to
express his feeling toward the patient’s “illness.” Different dynamics and patterns were
played with his tambourine. He stated that he could not explain what it was. The patient
slowly shared her thought on the music played by her husband, “The different dynamics
in the music may be the dynamics of our lives. There is an excitement and sometimes
not,” and the husband agreed with her (see Table 16). While repeating the improvisation,
the patient was asked to join in and the patient tired to communicate with her husband by
playing her instrument. The music ended up with a loud sound, and the expression of
both the patient and the husband matched each other. After the music ended the patient
offered the following interpretation: “It was an excitement in life. The ending was being
heaven with an excitement and we all have up and down in life but we also have a happy
ending,” which the patient already shared meant her going to heaven, meeting God, and
having no pain any more. The specific difference from the previous improvisation was
that her husband nodded his head while he listened to the patient. This might mean that
he had moved toward more toward acceptance, after he had expressed his deep innermost

feelings to his loved one.

74

Table 15. Summary of the Fourth Improvisation in Session 5

 

 

 

Music Therapist (MT) Patient (PT) Spouse (SP)
0 Asked PT to play Played a random, non- Chose a hand drum and
keyboard with MT harmonized melody, followed PT’s pattern,

and to express her
“illness”

Asked what the
melody that PT played
meant to her

Asked what
“happiness” that PT
mentioned meant to
her

 

and went up and down
on the keyboard

“The sound at the
bottom makes me sad,
and I didn ’t want to
stay there, so I went
up, but still went down
and up again. I
sometimes go into a
bad mood because of
illness, but I don ’t
want to give up
fighting and on my
health.”

Shared that she felt it
was as if SP tried to
support her and
encourage her from
when she was fighting
with her illness to
when she was going to
“happiness.”

Stated that happiness
at the end of music for
her meant going to
heaven, meeting God,
having no pain as well
as being surrounded by
her family

Quietly looked at SP

 

and matched his drum
pattern with PT ’8
pattern at the end

Quietly listened to PT

Responded, “As long
as she looks happy and
alright, I ’m happy and
I’m not worried. "

Stated that he had not
accepted PT’s illness
and what was going to
happen to her “yet”
because what he saw
right now was PT doing
alright, but he said he
would accept whatever
God was going to
happen to PT and him.
After he shared that, he
had tears on his eyes

 

75

 

Table 16. Summary of the Last Improvisation in Session 6

 

 

 

Music Therapist (MT) Patient (PT) Spouse (SP)
0 Encouraged SP to Hesitated to play his
express his feeling tambourine, but slowly
toward PT’s illness in started shaking his

music

Asked SP what the
sound meant to him

Asked PT to join in
playing the drum that
PT chose and to
communicate with SP
in music

 

Instead of SP, shared
what she felt that he
expressed. “The
difi‘erent dynamics in
the music may be the
dynamics of our lives.
There is an excitement
and sometimes not.”

Made an eye contact
with SP

Shared that she was
trying to talk to SP
with her instrument
and to match SP’s
tambourine patterns
Ended up with a loud
sound

Explained, “It was an
excitement in life.”
“The ending was
being heaven with an
excitement and we all
have up and down in
life but we also have a
happy ending.”

 

tambourine and made
some different
dynamics in the music
Stated that he could not
explain what it was, but
agreed with her sharing

Made an eye contact
with PT

Ended up with a loud
sound

Quietly listened to PT
and nodded his head

 

76

 

CHAPTER SEVEN
Discussion and Conclusions
Cases One and Two in this research study were two completely separate cases. Due
to the uniqueness of the two cases, individualized music therapy plans were based on
careful assessment findings. Their needs and goals were crucial in providing the
participants with the best possible care. During an initial assessment and for each music
therapy session, the music therapist strove to provide and suggest the best possible music
therapy interventions for the patients and their spouses. It was necessary for the music
therapist to make plan adjustments on the spot, remain flexible and sensitive to patient
needs and take into consideration each patient’s age, gender, cultural background,
religious beliefs, and the stage of the cancer. Individually preferred activities, such as
singing favorite songs, listening to meaningful songs or music, playing musical
instruments, etc., enhanced their reminiscence and brought them back to their “good old
days” and facilitated more expression of their feelings. With these meaningful songs or
music, the patients and their spouses were smiling and laughing as they expressed
positive emotions. This provided meaningful interactions between the patients and their
spouses, as was pointed out in several earlier studies (Bailey, 1984; Gilbert, 1977;
Jackson, 1995; Martin, 1991).
Case One
Although the patient and his wife in Case One exhibited a number of positive
responses through in the music therapy sessions, which was evident in the qualitative data,
no significant differences were found on the patient’s quality of life level and the

spouse’s stress level in the quantitative analysis. When the music therapist interviewed

77

the patient after the final music therapy intervention, he said that he enjoyed music
therapy and thought that it helped distract from and decrease the sensation of pain during
the sessions. Also, the patient neither agreed nor disagreed that music therapy helped
improve his quality of life (Question 10 on Quality of Life Questionnaire) at
measurement points eight and nine when he was having a difficult time engaging in
music therapy, although he agreed that music helped improve his quality of life in
measurement periods two through seven.

It is possible that both the patient and his wife, especially the patient, were not able
for physical reasons caused by his disease to spend adequate time in music therapy to
allow him and his wife to express what they needed to express. These limitations only
allowed them to participate in one activity in each session and then only for 30 minutes.
Also, the patient often fell asleep during music therapy as he was not able to have enough
rest and sleep due to chronic headaches.

The patient’s wife also expressed positive feelings about the music therapy during
the interview at the end of the last session. She mentioned that she was an artistic person
so that music was her outlet to express her feeling and release her stress through the song
that they wrote, at a time when she had no other outlet to express her feelings. However,
the wife’s stress level did not significantly change, although visual inspection of the data
may indicate that a trend of decreased stress was beginning to occur. Since this was at the
end of the sessions, there is no way to determine if that trend would have continued had
the sessions continued. It is tempting to speculate that with more time of participation in

music therapy and even more variety in the music therapy interventions, that the

78

increased time with her husband may have produced significant change. In particular,
more time in song writing may have made a difference.
Case Two

The couple in Case Two was able to participate in both their preferred activities
and suggested activities in music therapy. They had more opportunities to enjoy fun
activities to release their tension and stress, as well as to communicate through verbal
discussion and through the music. These were two different opportunities for them to
express what they were having to deal with. They became much more open toward the
end, as compared with how they were in the first session. They both were able to express
how they felt about the patient’s illness through the music experiences and to share this
not only with the music therapist but also with each other. Whereas the husband had had
a difficult time to accept the reality happening to his wife, he gradually started expressing
his feelings toward his wife and her illness with tears and sharing his thoughts. The
patient’s quality of life level significantly improved and her husband’s stress level also
significantly decreased, which occurred when they walked side by side in this process
through the music therapy process. The patient also sensed that music therapy helped
improve her quality of life, as the patient circled on “strongly agree” on question 10 of
the Quality of Life Questionnaire regarding her perception that music therapy helped
improve her quality of life every time the questionnaire was administered.

The patient realized and told her husband how much he was able to support her,
and how much her family meant to her. After the patient shared her feeling in the music

therapy sessions, her husband’s stress level significantly decreased. Although the

79

husband was shy, this verbal appreciation to him and theirifamily helped him get out
from denial and move toward acceptance.

The husband’s stress level significantly decreased after session 2 when the patient
became more able to express her emotions with her smiles and laughter through the
music experiences. The husband stated that he felt happy when he saw that his loved one
looked happy. However, he was still not fully able to acknowledge the intense feeling he
held inside. In the final week of the music therapy he was again able to feel a great deal
of stress reduction. At that time both the patient and her husband became much more
open about sharing what they were thinking and feeling. The patient expressed her
appreciation to her husband for supporting her, and shared her thoughts about a “happy
ending” when she would be going to heaven and meeting God, and have no pain, and be
surrounded by her family. The husband was then more able to express his emotions about
the patient’s illness and the reality of what was going to happen to his loved one. This
happened during the improvisation in session 5. Not only did he share how he felt, but he
also became tearful. His acceptance of his wife’s impending death occurred in session 6,
which was the last session for them, and the patient’s quality of life significantly
improved after the session.

Enhancing and maintaining their spirituality through their music making was
important for the couple in Case Two. The patient had a better understanding of the
meaning of life, and her husband accepted the reality for her death through his spiritual
belief that God was in charge of whatever was going to happen to them. Mutual
effectiveness of music therapy for both the patient and her husband was demonstrated

with this couple through the six music therapy sessions across three weeks.

80

Implications from two cases

Case Two suggests how music therapy can mutually influence quality of life in a
terminally ill patient, while reducing the stress of the patient’s spouse when they are
going through a difficult time at the end of a life. It was shown that this was able to occur
in the course of three weeks when the dying patient and the spouse had adequate time in
music therapy with the professional music therapist to “work through” their feelings with
verbal discussions and also through the music. On the other hand, the couple in Case One
had more limited exposure to music therapy and the discussions around what they
experienced in the music. This indicates that the importance of involving participants in
music experiences facilitating and making it possible for them to uncover and express
their feelings and thoughts concerning end of life that they are going through. In this
study, song writing (fill—in-blank and writing one’s own song), lyric discussion, and
musical improvisation were effective in terms of facilitating the expression of feelings. In
particular, improvisation was a highly effective way for the couple in Case Two to come
together in their difficult time. As Decuir (1991) states, music therapy was more effective
than verbal methods, as it is nonverbal making it possible for patients and their family
members to more easily express their feelings in the enjoyable, non-threatening structure
of music therapy.

Another finding was the importance of dealing with “unfinished business.”
Whereas the couple in Case Two touched “unfinished business” when the husband
moved from “denial” to “acceptance” through the process of music therapy, the couple in
Case One did not have ample time in music therapy to deal with their “unfinished

business.” For example, the patient in Case One, while able to express that he wished to

81

sing the song “The Rose” for their wedding, this wish was denied by the officiating
clergy. However, if he had had more time in music therapy to work through his feelings,
in addition to expressing and releasing them, he might have been able to complete his
“unfinished business.”

Leaving a legacy is also recommended for terminally ill patients and their family
members. Jackson (1995) discusses in her study that the videotape of the patient’s funeral
concert remained a legacy by for the family to remember her. The couple in Case One
started writing a song together for her funeral service They discussed a theme for the
song, brainstormed what to write, and wrote down the lyrics. Although their song was not
completed before the patient died, his wife shared her feelings about this activity when
the music therapist interviewed her, “Now, that song is infamous with our group of
friends. I played it and sang it New Year’s Day at a party. Everyone loves it and thinks I
should give it to some friends of ours who are a band to play it at their shows. But even if
no one else ever hears it, our friends will always remember that moment and how much it
meant to Tim. And I will always treasure it.”

It is also important to focus on how much the participants were able to
communicate outside the music therapy sessions, and how much these communications
were being facilitated and enhanced by the experiences in music therapy. The couple in
Case Two and their family members shared that they had opportunities to enjoy music
not only during the music therapy sessions but also after the music therapist left. The
family mentioned that the patient played organ as she was motivated to practice although
she had not had touched the instrument for a long time, that she sang the songs sung after

the music therapist left, listened to the tape of those songs provided by the music therapist,

82

and danced with her family members. As Bright (2002) and Hogan (1999) suggested,
recorded music was effective in meeting their needs when the music therapist was not
available. She enjoyed music and her quality of life was improved with it, and not just
during the music therapy sessions. It is crucial that the understandings and skills from the
music therapy sessions be generalized to the times when the music therapist is not around,
since strategies of dealing with physical and emotional distress need to be available 24
hours a day to both the patient and the caregiver. The music therapist is responsible for
making certain that these strategies carry over outside the music therapy sessions.
Recommendations for future research

In the present study, it was difficult obtaining an adequate number of participants
for a quantitative study. One of the possible reasons is due to the difficulty of scheduling
of both patients and their families for all six music therapy interventions and nine
questionnaires for three weeks. For some candidates from a hospice organization, the
schedule of this research design might overwhelm them due to participation in several
interventions and filling out questionnaires several times. It is recommended that the
number of visits for both patients and their families be lessened so patients and families
would feel less overwhelmed. In addition, several questions on SCARED used in the
present study for caregivers appeared to threaten caregivers or make them feel
uncomfortable to answer, particularly at a time when the terminally ill patients and their
family members were sensitive and fragile during difficult times. An example of the
above was when a patient’s caregiver requested to withdraw from the study as the result
of difficult questions on SCARED. He stated that he felt those questions were intrusive

and too intense. For the future research, the use of questionnaires with non-threatening

83

wording and phrases, which are sensitively and carefully chosen, is recommended. Both
patients in Cases One and Two in this study were easily able to answer all the questions

each time on all items for the Quality of Life questionnaire. More lengthy questionnaires
were more difficult for patients to complete.

Conclusion

A small number of participants were available for this study, and quantitative data
for analyses were limited. However, the results from both the quantitative and qualitative
data sources and the implications from the data sources support the effectiveness of
music therapy for both the quality of life of the terminally ill patient and the stress level
of the spouse or caregiver. The findings of this study support the importance of music
therapists not only providing the patient and family with meaningful experiences and
quality communication strategies, but also opportunities for them to uncover and work
through needs which they might not even be aware of. The data from the present study
suggest that as that patient’s quality of life improves, the caregiver’s distress may be
decreasing at the same time.

It is important for both terminally ill patients and their family members to be
supported and for therapists to facilitate meaningful release for the patients and those
who love them. These times and opportunities would make a difference in terms of
providing both the patients and their family members with meaningful final moments
together, as Robert E. Krout (2003) stated:

It is important for the music therapist and other care team members to remember
that the final days and hours of a patient’s life are times for helping loved ones to

visit and say goodbye in their own ways and styles. It is during these times that

84

we as members of the hospice team can provide support and facilitate meaningful

release for both the patients and those who love them. (p. 133)
This statement is a maxim for all music therapists who work with terminally ill patients
and their family members or loved ones. In the final moments in the life of a terminally
ill patient, music therapists often find that there are needs which can be met, what the
family hopes to accomplish during that time, some things that the music therapists are
able to do for them in those moments, and how music therapists can support both
terminally ill patients and their family members by facilitating meaningful moments and

communication with each other.

85

APPENDIX A

RESEARCH CONSENT FORM

TITLE OF RESEARCH: “The effectiveness of music therapy involving family
members of terminally ill patients in hospice on quality of life of the patients and
stress level of family members”

RESEARCHER: Ayumu Kitawaki
Music Therapy Graduate Student
School of Music
Michigan State University

SUPERVISOR: Frederick Curtis Tims, Ph.D., MT-BC
Professor and Chair of Music Therapy
School of Music
Michigan State University

You are being asked to participate in a research study designed to test the
effectiveness of music therapy interventions involving family members of
terminally ill patients in hospice on quality of life of the patient and stress levels of
family members. The purposes of this study are: 1) to determine whether
terminally ill patients who receive music therapy interventions with their family
members show higher quality of life than before the three-week intewention, and
2) to determine whether the family members of terminally ill patients who are
involved music therapy interventions demonstrate lower stress levels than before
the three-week intervention.

If you decide to participate in this research study, the music therapy session will
be held for you and your family or loved one. The maximum time period of every
music therapy session will be between 30 minutes and one hour. The strategies
used in the session will be flexible and adapted to individual situations as they
arise. The music therapy sessions will be held twice a week, and you will be
encouraged to complete a questionnaire regarding quality of life three times a
week. You may take approximately ten minutes to complete the questionnaire.
The weekly plan that you will be encouraged to participate in is as follows:

Day 1: Questionnaire

Day 2: Neither music therapy session nor questionnaire
Day 3: Music therapy session

Day 4: Questionnaire

Day 5: Neither music therapy session nor questionnaire
Day 6: Music therapy session

Day 7: Questionnaire

86

APPENDIX A (Continued)

From this questionnaire, information regarding the relationship of music therapy
to your quality of life and how music therapy may influence stress levels of your
family member or loved one will be collected. This information will be used for my
Master’s thesis in the graduate music therapy program of Michigan State
University.

There is no known harm associated with your participation in this research.
However, you may experience some distress by talking and thinking about the
stories of your life, which you do not feel comfortable sharing during the music
therapy sessions. If this occurs, the researcher will not push you to share more
about your stories. You can end your participation in this study anytime if you do
not feel comfortable with the experience.

The foreseeable benefits of participating in this research are as follows: 1) You
may accept or build the better relationships with your family member or loved one,
2) You may have more conversation with your family member or loved one, and
3) You may experience the beauty of music and how it may positively influence
your quality of life with your family member or loved one. While it is possible that
you may not notice personal benefit from your participation in this research, your
participation may provide valuable information to the music therapy community
about the effectiveness of music therapy for terminally ill patients and family.

Confidentiality will be respected. No information that discloses your identity will
be released or published without your specific consent to the disclosure except
as required by law. However, it is important to note that the original signed
research consent (and the data which will follow) will be included in your record.
This study will take place only for you and your family member or loved one.
Nobody except you, your family member or loved one, and a music therapist will
be present while the music therapy session is held and you answer the
questionnaire regarding quality of life. The researcher will assign a code number
to you, and only the researcher will be able to see your name. Data will be
analyzed using the code number for identification. The consent form will be
shredded at the completion of the study. The researcher will do his best to
protect your confidentiality. Your privacy will be protected by the maximum extent
allowable by law.

Written data will be stored in the locked cabinet in the researcher’s office. Other
data will be securely processed and stored in the researcher’s computer at his
home. Only the researcher will have access to the locked cabinet and the
questionnaire forms that you complete. Only the researcher can access other
data and documents in the researcher’s computer with the password.

87

APPENDIX A (Continued)

Your participation in this research is voluntary; you have the right to withdraw at
any point of the research, for any reason, and without any prejudice, and the
information collected and records and reports written will be tumed over to you.
You may choose not to participate at all, or you may refuse to participate in
certain procedures or answer certain questions or discontinue your participation
at any time without penalty or loss of benefits.

You are encouraged to ask any questions at any time regarding the nature of the
research and the method that the researcher is using. Your suggestions and
concerns are important to the researcher; please contact me at any time, Tel:
(517)-337-0586, Email: kitawakt @msu.edu, Regular mail: 124 Cedar St. Apt #1,
East Lansing, MI 48823. You may also contact Dr. Frederick Curtis Tims, the
research supervisor, Tel: (517)-353-9122, Email: tims@msu.edu, Regular mail:
102 Music Building Michigan State University. Moreover, if you have any
questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may anonymously
contact if you wish — Peter Vasilenko, Ph.D., Director of the Human Research
Protection Program, by phone: (517)-355-2180, fax: (517)-432-4503, email
address: irb@ores.msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI
48824.

As a participant, l voluntarily agree to participate in this research:

Participant Date

 

As a researcher, I agree to the terms:

Researcher Date

 

88

APPENDIX B

Research Consent Form

TITLE OF RESEARCH: “The effectiveness of music therapy involving family
members of terminally ill patients in hospice on quality of life of the patients and
stress level of family members”

RESEARCHER: Ayumu Kitawaki
Music Therapy Graduate Student
School of Music
Michigan State University

SUPERVISOR: Frederick Curtis Tims, Ph.D., MT-BC
Professor and Chair of Music Therapy
School of Music
Michigan State University

You are being asked to participate in a research study designed to test the
effectiveness of music therapy interventions involving family members of
terminally ill patients in hospice on quality of life of the patient and stress levels of
family members. The purposes of this study are: 1) to determine whether
terminally ill patients who receive music therapy interventions with their family
members show higher quality of life than before the three-week intervention, and
2) to determine whether the family members of terminally ill patients who are
involved music therapy interventions demonstrate lower stress levels than before
the three-week intervention.

If you decide to participate in this research study, the music therapy session will
be held for you and your loved one. The maximum time period of every music
therapy session will be-between 30 minutes and one hour. The strategies used in
the session will be flexible and adapted to individual situations as they arise. The
music therapy sessions will be held twice a week, and you will be encouraged to
complete a questionnaire regarding stress level three times a week. You may
take approximately ten minutes to complete the questionnaire. The weekly plan
that you will be encouraged to participate in is as follows:

Day 1: Questionnaire

Day 2: Neither music therapy session nor questionnaire
Day 3: Music therapy session

Day 4: Questionnaire

Day 5: Neither music therapy session nor questionnaire
Day 6: Music therapy session

Day 7: Questionnaire

89

APPENDIX B (Continued)

From this questionnaire, information regarding the relationship of music therapy
to your stress level and how music therapy may influence your loved one’s
quality of life will be collected. This information will be used for my Master’s
thesis in the graduate music therapy program of Michigan State University.

There is no known harm associated with your participation in this research.
However, you may experience some distress by talking and thinking about the
stories of your life, which you do not feel comfortable sharing during the music
therapy sessions. If this occurs, the researcher will not push you to share more
about your stories. You can end your participation in this study anytime if you do
not feel comfortable with the experience.

The foreseeable benefits of participating in this research are as follows: 1) You
may accept or build the better relationships with your loved one, 2) You may
have more conversation with your loved one, and 3) You may experience the
beauty of music and how it may positively influence your stress level with your
loved one. While it is possible that you may not notice personal benefit from your
participation in this research, your participation may provide valuable information
to the music therapy community about the effectiveness of music therapy for
terminally ill patients and family.

Confidentiality will be respected. No information that discloses your identity will
be released or published without your specific consent to the disclosure except
as required by law. However, it is important to note that the original signed
research consent (and the data which will follow) will be included in your record.
This study will take place only for you and your loved one. Nobody except you,
your loved one, and a music therapist will be present while the music therapy
session is held and you answer the questionnaire regarding stress level. The
researcher will assign a code number to you, and only the researcher will be able
to see your name. Data will be analyzed using the code number for identification.
The consent form will be shredded at the completion of the study. The researcher
will do his best to protect your confidentiality. Your privacy will be protected by
the maximum extent allowable by law.

Written data will be stored in the locked cabinet in the researchers office. Other
data will be securely processed and stored in the researchers computer at his
home. Only the researcher will have access to the locked cabinet and the
questionnaire forms that you complete. Only the researcher can access other
data and documents in the researcher’s computer with the password.

Your-participation in this research is voluntary; you have the right to withdraw at
any point of the research, for any reason, and without any prejudice, and the

90

APPENDIX B (Continued)

information collected and records and reports written will be turned over to you.
You may choose not to participate at all, or you may refuse to participate in
certain procedures or answer certain questions or discontinue your participation
at any time without penalty or loss of benefits.

You are encouraged to ask any questions at any time regarding the nature of the
research and the method that the researcher is using. Your suggestions and
concerns are important to the researcher; please contact me at any time, Tel:
(517)-337-0586, Email: kitawak1 @msu.edu, Regular mail: 124 Cedar St. Apt #1,
East Lansing, MI 48823. You may also contact Dr. Frederick Curtis Tims, the
research supervisor, Tel: (517)-353-9122, Email: tims@msu.edu, Regular mail:
102 Music Building Michigan State University. Moreover, if you have any
questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may anonymously
contact if you wish — Peter Vasilenko, Ph.D., Director of the Human Research
Protection Program, by phone: (517)-355-2180, fax: (517)-432-4503, email
address: irb@ores.msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI
48824.

As a participant, I voluntarily agree to participate in this research:

Participant Date

 

As a researcher, I agree to the terms:

Researcher Date

 

91

BIBLIOGRAPHY

Aasgaard, T. (1999). Music therapy as milieu in the hospice and paediatric oncology
ward. In D. Aldridge (Ed.), Music Therapy in Palliative Care: New Voices (pp. 29-
42). London: Jessica Kingsley Publishers.

Aldridge, G. (1996). Music therapy and practice in medicine: from out of the silence.
London: Jessica Kingsley Publishers.

Aldridge, G. (1999). Music therapy and the creative act. In D. Aldridge (Ed.), Music
therapy in palliative care: New Voices (pp. 15-28). London: Jessica Kingsley
Publishers.

Bailey, L. M. (1983). The effects of live music versus tape-recorded music on
hospitalized cancer patients. Music Therapy, 3(1), 17-28.

Bailey, L. M. (1984). The use of songs in music therapy with cancer patients and their
families. Music Therapy, 4(1), 5-17.

Beggs, C. (1991). Life review with a palliative care patient. In K. E. Bruscia (Ed.), Case
studies in music therapy (pp. 611-616). Phoenixville: Barcelona Publishers.

Bright, R. (1986). Grieving: A handbook for those who care. St. Louis: MMB Music.

Bright, R. (2002). Supportive eclectic music therapy for grief and loss: A practical
handbook for professionals. St. Louis: MMB Music.

Byock, I. R. (1998). Measuring quality of life for patients with terminal illness: The
Missoula-VITAS® Quality of Life index. Palliative Medicine, 12(4), 231-244.

Cheng, W. C., Schuckers, P. L., Hauser, G., Burch, J ., Emmett, J. G., Walker, B., Law, E.,
Wakefield, D., Boyle, D., Lee, M., & Thyer, B. A. (1994). Psychosocial needs of

family caregivers of terminally ill patients. Psychological Reports, 75(3), 1243-
1250.

Clair, A. A. (1997). The effects of music therapy on interactions between family
caregivers and their care receivers with late stage dementia. Journal of Music
Therapy, 34(3), 148-164.

Cohen, S. R., Mount, B. M., Strobe], M. G., & Bui, F. (1995). The McGill Quality of Life
Questionnaire: a measure of quality of life appropriate for people with advanced
disease: A preliminary study of validity and acceptability, Palliative Medicine, 9(3),
207-219.

92

Cresswell, J. W. & Piano Clark, V. L. (2007). Designing and Conducting Mixed Methods
Research. California: Sage Publications.

Decuir, A. L. (1991). Trends in music and family therapy. Arts in Psychotherapy Special
Issue: The creative arts therapies and the family, 18(3), 195-199.

de Montigny, J. (1993). Distress, stress and solidarity in palliative care. Journal of Death
& Dying. 27(1), 5-15

Fagen, T. S. (1982). Music therapy in the treatment of anxiety and fear in terminal
pediatric patients. Music Therapy, 2(1), 13-23.

Fuller, R. L., & Geis, S. (1985). Communicating with the grieving family. Journal of
Family Practice, 21(2), 139-144.

Gilbert, J. P. (1977). Music therapy perspectives on death and dying. Journal of Music
Therapy, 14(4), 165-171 .

Hilliard, R. E. (2001). The use of music therapy in meeting the multidimensional needs of
hospice patients and families. Journal of Palliative Care, 17(3), 161-166.

Hilliard, R. E. (2003). The effects of music therapy on the quality and length of life of
people diagnosed with terminal cancer. Journal of Music Therapy, 40(2), 113-137.

Hogan, B. (1999). Music Therapy at the End of Life: Searching for the Rite of Passage.
In D. Aldridge (Ed.), Music Therapy in Palliative Care: New Voices (pp. 68-81).
London: Jessica Kingsley Publishers.

Hull, M. M. (1990). Sources of stress for hospice caregiving families. Hospice Journal
Special Issue: F amily-based palliative care, 6(2), 29-54

Jackson, M. (1995). Music therapy for living: A case study on a woman with breast
cancer. Canadian Journal of Music Therapy, 3(1), 19-33.

Kelly, B., Burnett, P., Pelusi, D., Badger, S., Varghese, F., & Robertson, M. (2002).
Terminally ill cancer patients' wish to hasten death. Palliative Medicine, 16(4),

339-345.

Kristjanson, J. (1989). Quality of terminal care: Salient indicators identified by families.
Journal of Palliative Care, 5(1), 21-30.

Krout, R. E. (2003). Music therapy with imminently dying hospice patients and their
families: Facilitating release near the time of death. American Journal of Hospice

& Palliative Care, 20(2), 129-133.

Kubler-Ross, E. (1969). On Death and Dying: New York, Macmillan.

93

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage
Publications.

MacLachlan, S. (1999). Angel. On Surfacing [CD]. New York: Arista Records.

Maranto, C. D. (1993). Music therapy and stress management. In P. M. Lehrer & R. L.
Woolfolk (Ed.), Princlples and Practice of Stress Management. (pp. 407-442).
New York: The Guildford Press.

Marr, J. (1998-1999). GIM at the end of life: Case studies in palliative care. Journal of
the Association for Music & Imagery, 6, 37-54.

Martin, J. A. (1991). Music therapy at the end of life. In K. E. Bruscia (Ed.), Case
studies in music therapy (pp. 617—632). Phoenixville: Barcelona Publishers.

Midler, B. (1979). The Rose [written by Amanda McBroom]. On The Rose: The Original
Soundtrack Recording [CD]. New York: Atlantic Records.

Munro, S. (1984). Music therapy in palliative/hospice care. St. Louis: Magnamusic-
Baston.

O'Callaghan, C. C. (1993). Communicating with brain-impaired palliative care
patients through music therapy. Journal of Palliative Care, 9(4), 53-55.

O'Callaghan, C. C. (1996). Lyrical themes in songs written by palliative care patients.
Journal of Music Therapy, 33(2), 74-92.

Pelletier, C. L. (2004). The effect of music on decreasing arousal due to stress: A
meta-analysis. Journal of Music Therapy, 41(3), 192-214.

Peters, J. S. (1987). Music therapy: An introduction. Springfield: Charles C Thomas
Publishers.

Prigerson, H. G., Cherlin, E., Chen, J. H., Kasl, Stanislav V., Hurzeler, R., & Bradley, E.
H. (2003). The stressful caregiving adult reactions to experiences of dying
(SCARED) scale: A measure for assessing caregiver exposure to distress in
terminal care. American Journal of Geriatric Psychiatry, 11(3), 309-319.

Ruud, E. (1997). Music and the quality of life. Nordic Journal of Music Therapy, 6(2),
86-97.

Smeijsters, H. (1997). Multiple Perspectives: A Guide to Qualitative Research in Music
Therapy. Gilsum, NH: Barcelona Publishers.

94

SmeijSters, H., & Aasgaard, T. (2005). Qualitative Case Study Research. In B. Wheeler
(Ed.), Music Therapy Research Second Edition (pp. 440—457). Gilsum, NH:
Barcelona Publishers.

Smeijsters, H., & Van Den Berk, P. (1995). Music Therapy with A Client Suffering from
Musicogenic Epilepsy: A Naturalistic Qualitative Single-Case Research. The Arts
in Psychotherapy, 22(3), 249—263.

Unkefer, R. F. & Thaut, M. H. (Ed.). (2005). Music therapy in the treatment of adult with
mental disorders. St. Louis, MO: MMB Music.

Vedhara, K., Shanks, N., Anderson, S., & Lightman, S. (2004). The role of stressors and
psychosocial variables in the stress process: A study of chronic caregiver stress.

Psychosomatic Medicine, 62(3), 374-385.

Weber, S. (1999). Music: A means of comfort. In D. Aldridge (Ed.), Music Therapy in
Palliative Care: New Voices (pp. 95-104). London: Jessica Kingsley Publishers.

95

MICH‘IGAN STATE UNIVERSITY LIBR

”II III llll llllllllls

93 03062 65 47

Ill